Case Study on Transgender Youth: Juanita Hodax, MD, and Catherine Sumerwell, DNP, ARNP
July 3, 2019
Summary: 10-year-old transgender male with gender dysphoria desiring pubertal suppression and to start testosterone in the future.
Patient History: The patient is a 10-year, 10-month-old child assigned female at birth who identifies as male. He started showing interest in wearing boys clothing around first grade, and in the last two to three years has been saying that he “wants to be a boy.” He now goes by his chosen name and uses he/him pronouns at school and at home, although his mom is still struggling with using these pronouns and name. He is out to his teachers and most of the kids at school, and most are supportive. The patient becomes very upset, aggressive and angry when people use the wrong name or pronoun. He has had some fights at school in these situations. Mom reports concern that the patient has been talking about hormones and surgery after doing some research on the Internet, and she worries about the permanency of these treatments. The patient started to have some pubertal changes, including breast development and pubic hair, three months ago, which has been distressing. He has not had any vaginal bleeding or discharge. The patient reports wanting a male body in the future and does not want to have breasts. He is very worried about menarche and wants to know what can be done to prevent his periods from starting.
The patient has a history of ADHD, currently treated with Concerta, Focalin and Intuniv, and also some aggressive behaviors in the past. He saw a therapist five years ago due to aggression, but has not seen a therapist regarding his gender dysphoria.
Patient Diagnosis: The patient has gender dysphoria, as his gender identity is incongruent with his sex assigned at birth, and this is causing him distress. Physical exam shows Tanner stage 2 breasts and pubic hair.
Labs/Imaging (if applicable): Laboratory evaluation showed early pubertal levels of luteinizing hormone (LH) 0.39 mIU/mL (>0.2 is consistent with puberty) and estradiol 16.3 pg/mL. A bone-age X-ray and DEXA scan were normal and consistent with chronological age. Vitamin D level was low with normal calcium.
Treatment and Discussion: Patients who are transgender have higher rates of suicide, self-harm, depression, anxiety, eating disorders, violence and bullying, family rejection and homelessness and risky sexual behaviors. Gender-affirmative care (oriented towards understanding a patient’s gender experience), parental and family support of affirmed gender identity and medical interventions with puberty blockers or gender-affirming hormones can help improve many of these mental health comorbidities and health disparities.
This patient is in early puberty, confirmed clinically with Tanner stage 2 breasts and confirmed biochemically with LH and estradiol in the Tanner stage 2 range. Early puberty is the ideal time to start puberty blockers in kids with gender dysphoria to prevent any further feminizing changes from puberty, which would be permanent. If breast development is prevented with puberty blockers, this can avoid the need for chest reconstruction surgery in the future. Puberty blockers are reversible, and endogenous puberty will return if treatment is discontinued. Our recommendation is to use puberty blockers alone for a maximum of four years because of concern for negative effects on bone mineral density if continued for longer. DEXA scan, vitamin D and calcium levels are assessed at baseline and monitored throughout treatment. For patients who have started puberty blockers and choose to pursue gender-affirming hormones, these are typically started at age 13.5 to 14 years, with the goal of puberty occurring at a peer-congruent time. Some patients may choose not to pursue gender-affirming hormones, and puberty blockers can be discontinued and natal puberty will resume.
If the patient were older and in later stages of puberty (Tanner 4/5) and >2 years post-menarche, puberty blockers might not be the best option for the patient, as there would be little further development of breast tissue to prevent and the risk of side effects (hot flashes, mood swings) increases with blocking higher levels of endogenous hormones that occur in later puberty. For these patients, we discuss options for menstrual suppression while preparing to start testosterone. Any hormonal contraceptive option that one may choose for menstrual suppression in a cisgender (non-transgender) individual would also be an option for a transgender individual. Common medications used in our clinic for this purpose include continuous OCPs, norethindrone, Depo-Provera injections, and LARCs including Mirena IUD and Nexplanon. These may be continued for menstrual suppression while the patient is beginning testosterone and then discontinued once testosterone is at a therapeutic level to suppress menses, or it can be continued for contraceptive purposes.
Outcome: The patient and his mother had four appointments with our gender clinic psychologist. Mom began using the patient’s chosen name, which decreased conflict between them. Patient and mom decided to move forward with puberty blockers, as mom realized how distressing a female puberty would be for the patient and she would like to stop this from happening and allow further time to explore gender with a mental health provider. The patient started Lupron 22.5 mg every 3 months, and puberty stalled based on clinical exam. He also had some regression in the breast buds that had developed. The patient is now engaged in weekly therapy and hopes to start testosterone when he turns 14 years old.
References:
Seattle Children’s Gender Clinic Website: https://www.seattlechildrens.org/clinics/gender-clinic/
Endocrine Society Guidelines: Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903. https://academic.oup.com/jcem/article/102/11/3869/4157558
UCSF Center of Excellence for Transgender Health: Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at www.transhealth.ucsf.edu/guidelines
AAP Policy Statement: Rafferty J, AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Committee on Adolescence, AAP Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018;142(4):e20182162. https://pediatrics.aappublications.org/content/142/4/e20182162