Gender affirming medical care of transgender youth

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.