Child and adolescent psychiatrists are seeing increasing numbers of transgender and gender-diverse children and teens. This podcast will help clinicians understand the basics of gender-affirming care (GAC) as they work with families around issues of gender dysphoria.

Published On: 09/18/2023

Duration: 14 minutes, 04 seconds

Transcript:

Dr. Feder: Gender-affirming care refers to medical, psychological, and social support provided to individuals whose gender identity differs from the sex they were assigned at birth. The core objective of gender-affirming care is to aid these individuals in mitigating the distress and discomfort caused by gender dysphoria which is a disparity between their gender identity and their assigned sex. This care framework also strives to enhance their holistic well-being and mental health. In this podcast, we will focus on helping clinicians understand the basics of gender affirming care as they work with families around issues of gender dysphoria.

Welcome to The Carlat Psychiatry Podcast.

This is another episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of the second edition of the Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Reports. 

As Dr. Feder mentioned earlier, gender affirming care—often referred to as GAC—is a multifaceted approach that clinicians can extend to patients seeking a gender expression that diverges from their assigned sex. However, it's essential to understand that gender-affirming care isn't confined to a singular procedure or methodology. It encompasses a spectrum of interventions that span from social transitions—like changes in attire and grooming—to hormone treatments that can either postpone the development of secondary sex traits or facilitate the emergence of traits associated with a different gender. Additionally, there are surgical options that can significantly alter gender expression. These procedures encompass diverse possibilities such as electrolysis, facial and tracheal cosmetic surgeries, mastectomy, phallectomy, vaginoplasty, and phalloplasty.

But it's important to avoid viewing these treatments as strictly binary outcomes. Patients often harbor preferences for specific interventions rather than seeking every conceivable procedure. It's a nuanced landscape where individualized care takes precedence over one-size-fits-all solutions.

Dr. Feder, where do people go for gender-affirming care, and what are the criteria for receiving it?

Dr. Feder: Patients have the option to receive gender-affirming care from various sources, including specialized health centers, nonprofit organizations that offer reproductive health services, college health centers, and individual endocrinologists and surgeons.

The World Professional Association for Transgender Health (WPATH) Standards of Care provide guidelines for determining the appropriateness of administering gender-affirming care to patients. Their recommended criteria encompass persistent and well-documented gender dysphoria, the capacity to make fully informed decisions and provide consent for treatment, the reasonable stabilization of significant medical or mental health considerations, and the ability to independently decide about pursuing gender-affirming care. For children and teens WPATH supports psychotherapy as part of the transition process to clarify the patient’s understanding and their own individual goals in pursuing gender affirming care. The actual availability of gender affirming care in the US varies from state to state, with some legislating restrictions on providing this care.  

 Mara: Recognizing the heightened vulnerability of gender diverse youth, it is imperative to address the elevated risks of mental health concerns, including depression and suicidal behaviors. This association was highlighted in a comprehensive review conducted in 2021, which aimed to estimate the prevalence of suicidal ideation and behaviors among gender non-conforming children, adolescents, and young adults. Employing a random-effects meta-analysis, the study evaluated outcomes related to non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts in youth up to age 25. The findings revealed a mean prevalence of 28.2% for NSSI, 28% for suicidal ideation, and a mean prevalence of 14.8% for suicide attempts. Trans youth are also at higher risk of victimization, particularly Black trans females.

Mara: Dr. Feder, what has research shown regarding the effectiveness of gender affirming care?

Dr. Feder: In a 2022 observational study assessing medical outcomes among transgender and nonbinary youth undergoing gender-affirming care, researchers discovered that such care led to a remarkable 60% reduction in depression rates and a substantial 73% decrease in suicidality for patients aged 13–20 over an 11-month period. However, a tangible risk remains: individuals who outwardly express their transgender identity often become susceptible to violent attacks.

Mara: Treatment approaches also vary depending on the individual's age. For younger children who haven't entered puberty yet, medical interventions are usually not involved. Instead, they might opt for a social transition, where they dress in a way that aligns with their internal gender identity. They might also request to be addressed by a different name and prefer specific pronouns.

Dr. Feder: On the other hand, for pubertal children experiencing gender dysphoria, the challenge lies in the development of secondary sex characteristics that might not align with their identity. In such cases, gender-affirming care often involves the use of gonadotropin-releasing hormone (GnRH) analogs. These medications serve to put a pause on the puberty process, usually offered around Tanner Stage II/IV. This approach allows these young individuals the time needed to explore the stability of their gender identity thoroughly.

Also by halting the progression of secondary sex characteristics, the need for some future surgeries is minimized. This includes procedures like mastectomy for transgender males or facial feminization and tracheal shaving for transgender females.

As patients move into later adolescence, it's common for them to initiate gender-affirming hormones, often referred to as hormone replacement therapy (HRT). For trans females, this might involve taking estrogen and progesterone, which aid in breast development and alter fat distribution. On the other hand, for trans males, the approach might involve testosterone or analogous hormones to stimulate facial hair growth and increase muscle mass.

Mara: Adolescence spans a considerable range of ages. Could you provide some clarity on the specific age range at which hormone replacement therapy is typically advised?

Dr. Feder: The guidelines set forth by the World Professional Association for Transgender Health suggest initiating hormone replacement therapy (HRT) around the ages of 14 to 16. However, this timeframe is somewhat arbitrary, and some individuals opt to begin HRT even earlier to achieve a more congruent appearance with their gender identity. It's worth noting that some people take charge of their own healthcare while away at college, pursuing HRT independently. The physical changes associated with HRT, like breast development and beard growth, occur gradually over several months. 

Surgical procedures, generally become accessible upon reaching the age of legal adulthood in the respective country or region. Nevertheless, some places might offer chest masculinization procedures at an earlier age.

Mara: A question that often arises for families and clinicians is the potential outcome if an individual undergoes an irreversible transition and then changes their mind. The majority of patients do not regret their initial decision, even if they later decide to halt the transition process. Shedding light on this, a recent study investigated the factors contributing to detransition among transgender and gender diverse individuals in the US. Among the participants, a substantial 61.9% (17,151) disclosed that they had engaged in some form of gender affirmation, encompassing a wide scope. Within this group, 13.1% (2242) had a history of detransition.

Among those who had detransitioned, 82.5% revealed that at least one external factor, for example family pressure, played a role in their decision. Interestingly, when it comes to hormonal treatments, over 98% of those who commence hormone replacement therapy (HRT) during adolescence continue with it. Yet, there is a growing concern regarding the potential impact of GnRH analogs on bone density, raising expectations for new guidelines encompassing bone density monitoring for these patients.

Dr. Feder: In this podcast, we've explored the realm of gender-affirming care and its role in supporting individuals whose gender identity deviates from their assigned sex at birth. gender-affirming care encompasses medical, psychological, and social assistance, with the overarching goal of alleviating gender dysphoria and bolstering mental well-being.

Gender-affirming care is not a one-size-fits-all approach; it spans a spectrum of interventions. From social transitions and hormone therapies to surgical procedures, gender-affirming care caters to individual preferences and needs.

Mara: Understanding the effectiveness of gender-affirming care is crucial. The research underscores the positive impact of gender-affirming care, with significant reductions in depression rates and suicidality observed among youth undergoing such care. Additionally, we've gained insights into the nuances of initiating HRT at different ages, highlighting the importance of individualized decisions and autonomy.

We also discussed concerns of detransition. While the majority of patients do not regret transitioning, studies shed light on the factors influencing detransition decisions. 

Nonetheless, we recognize the real risks faced by individuals who openly express their transgender identity, with concerns about violence and victimization. As we navigate the complexities of gender-affirming care, the ultimate aim remains the well-being of each individual and navigating a path toward supporting authentic expression of each individual's gender identity.

Dr. Feder: The clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

 And we have some exciting news for you! The podcast now has CME credits of its own. To get your credits for listening, follow the Podcast CME Subscription link in the show notes. It will link you to a CME post-test for this episode and for future episodes. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust. 

Mara: As always, thanks for listening and have a great day!

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.