Clinical Management of GID in Adolescents
Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects
Full text article via European Society of Endocrinology
Treatment outcome in transsexuals is expected to be more favourable when puberty is suppressed than when treatment is started after Tanner stage 4 or 5. In the Dutch protocol for the treatment of transsexual adolescents, candidates are considered eligible for the suppression of endogenous puberty when they fulfil the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable and live in a supportive environment. Suppression of puberty should be considered as supporting the diagnostic procedure, but not as the ultimate treatment. If the patient, after extensive exploring of his/her sex reassignment (SR) wish, no longer pursues SR, pubertal suppression can be discontinued. Otherwise, cross-sex hormone treatment can be given at 16 years, if there are no contraindications. Treatment consists of a GnRH analogue (GnRHa) to suppress endogenous gonadal stimulation from B2-3 and G3-4, and prevents development of irreversible sex characteristics of the unwanted sex. From the age of 16 years, cross-sex steroid hormones are added to the GnRHa medication.
Preliminary findings suggest that a decrease in height velocity and bone maturation occurs. Body proportions, as measured by sitting height and sitting-height/height ratio, remains in the normal range. Total bone density remains in the same range during the years of puberty suppression, whereas it significantly increases on cross-sex steroid hormone treatment. GnRHa treatment appears to be an important contribution to the clinical management of gender identity disorder in transsexual adolescents.
Transsexuals are applying for sex reassignment (SR) surgery at increasingly younger ages. Yet clinicians are usually reluctant to start the SR procedure before adulthood. They assume that adolescents are not able to make a sensible decision about something as drastic as SR. They fear that the risk of postoperative regrets will be high and the treatment will have unfavourable physical, psychological or social consequences. Postoperative regret or any other unfavourable result of SR naturally is of serious concern to clinicians. However, the decision of what age to start SR should be a balanced one. There are two main reasons to consider early treatment as appropriate.
One reason for early treatment is that an eventual delay or arrest in emotional, social or intellectual development can be warded off more successfully when the ultimate cause of this arrest has been taken care of. Suffering from gender dysphoria without being able to present socially in the desired social role, and/or to stop the development of secondary sex characteristics usually leads to problems in these areas. Adolescents find it hard to live with a secret. Often have difficulties in connecting socially and romantically with peers while still in the undesired gender role, or the physical developments create an anxiety that limits their capacities to concentrate on other issues.
A second reason to start SR early is that the physical treatment outcome following interventions in adulthood is far less satisfactory than when treatment is started at an age at which secondary sex characteristics have not yet been (fully) developed. Looking like a man (woman) when living as a woman (man) creates barriers that are not easy to overcome. This is obviously an enormous and lifelong disadvantage. Indeed, Ross and Need (1) found that postoperative psychopathology was primarily associated with factors that made it difficult for postoperative transsexuals to pass successfully to their new gender or that continued to remind them of their transsexualism. Furthermore, follow-up studies show that unfavourable postoperative outcome seems to be related to a late rather than an early start of the SR procedure (for a review, see (2)). Age at the time of assessment also emerged as a factor differentiating two groups of male-to-female transsexuals (MFs), one with and one without post-operative regrets (3).
The psychological problems of untreated adolescents and the impact of an unfavourable physical appearance significantly contributed to the decision of the Amsterdam Gender Clinic for Adolescents and Children to prescribe hormones before the age of 18 (legal adulthood). First, patients were considered eligible for a staged hormone treatment if they were (i) between 16 and 18 years, (ii) suffering from life-long gender dysphoria that had increased around puberty, (iii) functioning psychologically stable, and (iv) supported by their environment. For females, the staged approach consisted of treatment with progestagens to suppress menses for at least 3 months, followed by androgen treatment. For males, antiandrogens were given first, followed by oestrogens. The first retrospective and prospective studies among these transsexual adolescents, who were found eligible for treatment between 16 and 18 years, showed a significant postsurgery decrease in gender dysphoria, and an increase in body satisfaction. They were also functioning psychologically in the normal range, and did socially quite well (4, 5). They functioned psychologically better than transsexuals, who were treated in adulthood, and evaluated with partly the same instruments (6, 7). The policy implied that younger adolescents (between 12 and 16 years), who were referred for SR, had no other option than to wait for several years before they could be treated medically.
Since the experience of a full biological puberty may seriously interfere with healthy psychological functioning and well being, we have changed our protocol after the first follow-up studies on the 16–18-year olds (4, 5). Adolescents are now allowed to start puberty suppressing treatment with gonadotrophin-releasing hormone analogues (GnRHa) if they were older than 12 years of age and fulfil the same criteria as were used for the 16–18-year olds. They should also have reached Tanner stage 2 or 3 in combination with pubertal levels of sex hormones. The suppression of puberty using GnRHa is a reversible phase of treatment. This treatment is a very helpful diagnostic aid, as it allows the psychologist and the patient to discuss problems that possibly underlie the cross-gender identity or clarify potential gender confusion under less time pressure. It can be considered as ‘buying time’ to allow for an open exploration of the SR wish (8).
It is conceivable that lowering the age limit increases the incidence of ‘false positives’. However, it most certainly results in high percentages of individuals who more easily pass into the opposite gender role than when treatment commenced well after the development of secondary characteristics. This implies an improvement in the quality of life in these individuals, but may also result in a lower incidence of transsexuals with postoperative regrets or poor postoperative functioning. Clinically, it is known that some patients who were treated in adulthood regret SR because they have never been able to function inconspicuously in the opposite gender role. This holds especially for MFs, because beard growth and voice breaking give so many of them a never disappearing masculine appearance. But, since the number of ‘false positives’ should be kept as small as possible, the diagnostic procedure should be carried out with great care. Until now, no patients who started treatment before 18 years have regretted their choice for SR.
The Amsterdam Gender Clinic has developed the following protocol for the management of young applicants for SR and is currently evaluating this protocol in several studies.