New research confirms that transgender adolescents receiving pubertal blocking and/or gender-affirming hormone therapy report significant improvements in body dissatisfaction, with more moderate changes in depression and anxiety. This comes as no surprise to pediatric endocrinologist Julia Cartaya, MD, and pediatric psychologist Vanessa K Jensen, PsyD, both of Cleveland Clinic Children’s.
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“Although it may take several months of medication before a patient begins to see results from gender-affirming hormone therapy, the treatment does seem to improve body dissatisfaction,” says Dr. Jensen.
It’s important to note that hormone therapy encompasses two different types of therapy, explains Dr. Cartaya, Director of the Gender Understanding, IDentity and Expression (GUIDE) program at Cleveland Clinic Children’s.
“We can consider prescribing pubertal suppression via gonadotropin-releasing hormone for our younger patients who have reached Tanner Stage 2 and have a diagnosis of gender dysphoria from a mental health provider. As far as we are aware, the puberty blocking effects are entirely reversible. If a patient wants to stop, they can, and then would proceed through their body’s physiological puberty,” Dr. Cartaya says.
“The next step is feminizing or masculinizing hormone affirming therapy, which is either estradiol (and sometimes spironolactone) in patients designated male at births (trans women) or testosterone in patients designated female at birth (trans men). We follow the Endocrine Society’s clinical practice guidelines, which indicate that hormone-affirming therapy can begin at the age of mental maturity, which generally occurs around age 16. The changes associated with estradiol, spironolactone and testosterone are what we call semi-reversible, in that some of the changes will go back, but not all of them.”
It is important to note that parental consent is required for any medical therapy in children under the age of 18 years.
Gender-affirming hormone therapy is considered safe, but is not without risk, says Dr. Cartaya. The benefits include a general improvement in mental health functioning, a decrease in body dissatisfaction and an improved sense of wellbeing. The most significant risks with pubertal suppression are weight gain and decreases in bone mineral density, along with risks associated with injections or device placement. Risks with hormone therapy such as estradiol or testosterone are hormone dependent. With testosterone, there is an increased risk in heart disease, acne and infertility. It is also important to monitor increasing hemoglobin and hematocrit.
“There is also some concern about behavior changes, although our experience has been that, in general, transgender patients who start on testosterone therapy feel much happier and more comfortable with themselves, but for a few individuals there can be increases in anger and aggression,” states Dr. Jensen.
With estradiol treatment, there is an increased risk of blood clots, especially if you’re over the age of 35 and a smoker. Additional risks include stroke, in individuals who have migraine with aura, and infertility.
“I would say there are many clear advantages [to hormone affirming therapy]. There are always risks and there are still a number of unknowns,” Dr. Jensen cautions. “We don’t have a ton of experience about what happens 20, 30 or 40 years down the line. On a case-by-case basis, we know quite a bit about patients who transitioned as young adults and they’re largely doing well now in their 50s and 60s; however, there’s not been a lot of quantitative research that shows what happens long term, especially for those transitioning in their teen years.”
There’s a growing body of research into the association between mental health issues and transgender persons. In one study of the physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria, 35% reported depressive symptoms in the clinical range, and more than half of participants had considered suicide at least once. Another study cites a two- to three-fold increase in depression among transgender adolescents compared to their cisgender peers. However, these gender-related emotional issues tend to decrease with puberty suppression and gender-affirming hormone therapy.
“In those patients whose mental health symptoms are related to body dysphoria and gender identity, we tend to see an improvement in mood after several months of gender-affirming hormone therapy,” says Dr. Jensen. “There can be exceptions, however. If a patient experienced major distress before puberty, is having a difficult time at home or is being harassed at school, they may continue to struggle emotionally despite hormone therapy. It’s important to note that we encourage all our patients to have ongoing mental health therapy, especially before and then early in transition.”
“We require psychotherapy around gender for even the healthiest kids we see. Generally, we want at least six months of psychotherapy before the beginning of hormone therapy. We recommend continuing psychotherapy regularly for at least a couple of months, and if things appears stable, we may fade to a monthly check-in, and then periodically after that. Our goal is to know our patients and families well enough that they will reach out to check in if issues develop at any point during hormone therapy,” Dr. Jensen concludes.
For patients seeking care for transgender issues at Cleveland Clinic Children’s, the GUIDE program provides a wide range of support and intervention for youth (childhood through adolescent years) who are gender questioning, gender non-conforming, gender fluid or transgender, or who are struggling with any other issues around gender. The center provides care for all patients in a safe and welcoming environment. It includes providers who understand the health needs of LGBTQ patients, with a variety of specialists who are experts in LGBTQ care.