Doctor's Rec: WPATH Standards of Care for “Transsexual, Transgender, and Gender Nonconforming People”

The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments.

While this is primarily a document for health professionals, the SOC may also be used by individuals, their families, and social institutions to understand how they can assist with promoting optimal health for members of this diverse population.

Kaiser Permanente Transgender Care follows the WPATH standards of care and the 2009 Endocrine Society Guidelines, as well as a companion document for voice and communication change. Click through to access this file in 18 different languages.

Doctor's Rec: Puberty blockers can be life-saving for transgender teenagers. (Pediatrics)

Summary: Pubertal suppression therapy could significantly diminish their chances of suicide and mental health problems.

Title: Trends in the use of puberty blockers among transgender children in the United States.

Authors: Lopez CM, Solomon D, Boulware SD, Christison-Lagay ER

Journal: Journal of Pediatric Endocrinology and Metabolism

Publication date: 2018 Jun 27;31(6):665-670. doi: 10.1515/jpem-2018-0048.

Pub Med ID: 29715194 DOI: 10.1515/jpem-2018-0048. Available at https://www.ncbi.nlm.nih.gov/pubmed/29715194 .

BACKGROUND:

The objective of the study was to identify national trends in the utilization of histrelin acetate implants among transgender children in the United States.

METHODS:

We analyzed demographic, diagnostic and treatment data from 2004 to 2016 on the use of histrelin acetate reported to the Pediatric Health Information System (PHIS) to determine the temporal trends in its use for transgender-related billing diagnoses, e.g. "gender identity disorder". Demographic and payer status data on this patient population were also collected.

RESULTS:

Between 2004 and 2016, the annual number of implants placed for a transgender-related diagnosis increased from 0 to 63. The average age for placement was 14 years. Compared to natal females, natal males were more likely to receive implants (57 vs. 46) and more likely to have implants placed at an older age (62% of natal males vs. 50% of natal females were ≥;13 years; p<0.04). The majority of children were White non-Hispanic (White: 60, minority: 21). When compared to the distribution of patients treated for precocious puberty (White: 1428, minority: 1421), White non-Hispanic patients were more likely to be treated with a histrelin acetate implant for a transgender-related diagnosis than minority patients (p<0.001). This disparity was present even among minority patients with commercial insurance (p<0.001).

CONCLUSIONS:

Utilization of histrelin acetate implants among transgender children has increased dramatically. Compared to natal females, natal males are more likely to receive implants and also more likely to receive implants at an older age. Treated transgender patients are more likely to be White when compared to the larger cohort of patients being treated with histrelin acetate for central precocious puberty (CPP), thus identifying a potential racial disparity in access to medically appropriate transgender care.

Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care. (APA)

Source: American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70 (9), 832-864. doi: 10.1037/a0039906

Guideline 11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care.

Research has primarily shown positive treatment outcomes when TGNC adults and adolescents receive TGNC-affirmative medical and psychological services (i.e., psychotherapy, hormones, surgery; Byne et al., 2012; R. Carroll, 1999; Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008; Davis & Meier, 2014; De Cuypere et al., 2006; Gooren, Giltay, & Bunck, 2008; Kuhn et al., 2009), although sample sizes are frequently small with no population-based studies. In a meta-analysis of the hormone therapy treatment literature with TGNC adults and adolescents, researchers reported that 80% of participants receiving trans-affirmative care experienced an improved quality of life, decreased gender dysphoria, and a reduction in negative psychological symptoms (Murad et al., 2010).

In addition, TGNC people who receive social support about their gender identity and gender expression have improved outcomes and quality of life (Brill & Pepper, 2008; Pinto, Melendez, & Spector, 2008).

Several studies indicate that family acceptance of TGNC adolescents and adults is associated with decreased rates of negative outcomes, such as depression, suicide, and HIV risk behaviors and infection (Bockting et al., 2013; Dhejne et al., 2011; Grant et al., 2011; Liu & Mustanski, 2012; Ryan, 2009).

Family support is also a strong protective factor for TGNC adults and adolescents (Bockting et al., 2013; Moody & Smith, 2013; Ryan et al., 2010).

TGNC people, however, frequently experience blatant or subtle antitrans prejudice, discrimination, and even violence within their families (Bradford et al., 2007). Such family rejection is associated with higher rates of HIV infection, suicide, incarceration, and homelessness for TGNC adults and adolescents (Grant et al., 2011; Liu & Mustanski, 2012). Family rejection and lower levels of social support are significantly correlated with depression (Clements-Nolle et al., 2006; Ryan, 2009).

Many TGNC people seek support through peer relationships, chosen families, and communities in which they may be more likely to experience acceptance (Gonzalez & McNulty, 2010; Nuttbrock et al., 2009).

Peer support from other TGNC people has been found to be a moderator between antitrans discrimination and mental health, with higher levels of peer support associated with better mental health (Bockting et al., 2013).

Works cited:

  1. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943–951. http://dx.doi.org/10.2105/AJPH.2013 .301241

  2. Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco, CA: Cleis Press.

  3. Byne, W., Bradley, S. J., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41, 759 –796. http://dx.doi.org/10.1007/ s10508-012-9975-x

  4. Carroll, R. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education & Therapy, 24, 128 –136.

  5. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53– 69. http://dx .doi.org/10.1300/J082v51n03_04

  6. Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008). The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5, 1892–1897. http://dx.doi.org/10.1111/j .1743-6109.2008.00870.x

  7. Davis, S. A., & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in femaleto-male transgender people. International Journal of Sexual Health, 26, 113–128. http://dx.doi.org/10.1080/19317611.2013.833152

  8. De Cuypere, G., Elaut, E., Heylens, G., Van Maele, G., Selvaggi, G., T’Sjoen, G.,... Monstrey, S. (2006). Long-term follow-up: Psychosocial outcomes of Belgian transsexuals after sex reassignment surgery. Sexologies, 15, 126 –133. http://dx.doi.org/10.1016/j.sexol.2006.04.002

  9. Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS ONE, 6(2), e16885. http://dx.doi.org/10.1371/journal.pone.0016885

  10. Gooren, L. J., Giltay, E. J., Bunck, M. C. (2008). Long-term treatment of transsexuals with cross-sex hormones: Extensive personal experience. Journal of Clinical Endocrinology & Metabolism: Clinical and Experimental, 93, 19 –25. http://dx.doi.org/10.1210/jc.2007-1809

  11. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality & National Gay and Lesbian Task Force. Retrieved from http://endtransdiscrimination.org/PDFs/NTDS_Report .pdf

  12. Kuhn, A., Brodmer, C., Stadlmayer, W., Kuhn, P., Mueller, M. D., & Birkhauser, M. (2009). Quality of life 15 years after sex reassignment surgery for transsexualism. Fertility and Sterility, 92, 1685–1689. http:// dx.doi.org/10.1016/j.fertnstert.2008.08.126

  13. Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42, 221–228. http://dx.doi.org/10.1016/j.amepre .2011.10.023

  14. Moody, C. L., & Smith, N. G. (2013). Suicide protective factors among trans adults. Archives of Sexual Behavior, 42, 739 –752. http://dx.doi .org/10.1007/s10508-013-0099-8

  15. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systemic review and meta-analysis of quality of life and psychosocial outcomes.Clinical Endocrinology, 72, 214 –231. http:// dx.doi.org/10.1111/j.1365-2265.2009.03625.x

  16. Pinto, R. M., Melendez, R. M., & Spector, A. Y. (2008). Male-to-female transgender individuals building social support and capital from within a gender-focused network. Journal of Gay and Lesbian Social Services, 20, 203–220. http://dx.doi.org/10.1080/10538720802235179

  17. Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children. San Francisco, CA: Family Acceptance Project, Marian Wright Edelman Institute, SanFrancisco State University. Retrieved from http://familyproject.sfsu.edu/files/FAP_English%20Booklet_pst.pdf

  18. Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescence and the Health of LGBT Young Adults, 23, 205–213.

Doctor's Rec: 64,000+ pediatricians recommend gender-affirming treatment for children based on best available evidence

A September 2015 presentation from the American Academy of Pediatrics notes that treatment recommendations are based on the best available evidence. Their guidance defined three approaches to gender dysphoria in children: “corrective,” “supporting,” and “affirming,” with the AAP advising the “affirming” approach to gender dysphoria in children.



Sources:

  1. Kim Lacapria. (2016) American Pediatricians Issue Statement That Transgenderism Is ‘Child Abuse’? It was an official-sounding but fringe group of politically motivated pediatricians who issued a statement on gender, not the respected American Academy of Pediatrics. Snopes (6 May 2016) (pdf).

  2. Robert Garofalo. (2015) Understanding Gender Nonconformity in Childhood and Adolescence. American Academy of Pediatrics (September 2015). (pdf).

Doctor's Rec: Statement from American Academy of Pediatrics

The official American Academy of Pediatrics published (link to summary article) 9 clear recommendations for caring for youth and adolescents who identify as transgender or gender-diverse.

I highlight the portions that specify providing health care according to what the youth wants, especially to match the youth’s gender expression. Not parent, guardian, teacher, staff member, administrator, guidance counselor, etc.

[Aside: You may have heard a FoxNews Glenn Beck headline about an anti-gay-marriage hate group calling itself “American Pediatricians” creating a hoax claiming supporting a transgender youth is abuse. Read more about how Snopes debunked this, as well as the American Academy of Pediatrics’ internal presentation recommending affirming a child’s gender expression (pdf). —RXS]

1. that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space;

2. that family-based therapy and support be available to recognize and respond to the emotional and mental health needs of parents, caregivers, and siblings of youth who identify as TGD;

3. that electronic health records, billing systems, patient-centered notification systems, and clinical research be designed to respect the asserted gender identity of each patient while maintaining confidentiality and avoiding duplicate charts;

4. that insurance plans offer coverage for health care that is specific to the needs of youth who identify as TGD, including coverage for medical, psychological, and, when indicated, surgical gender-affirming interventions;

5. that provider education, including medical school, residency, and continuing education, integrate core competencies on the emotional and physical health needs and best practices for the care of youth who identify as TGD and their families;

6. that pediatricians have a role in advocating for, educating, and developing liaison relationships with school districts and other community organizations to promote acceptance and inclusion of all children without fear of harassment, exclusion, or bullying because of gender expression;

7. that pediatricians have a role in advocating for policies and laws that protect youth who identify as TGD from discrimination and violence;

8. that the health care workforce protects diversity by offering equal employment opportunities and workplace protections, regardless of gender identity or expression; and

9. that the medical field and federal government prioritize research that is dedicated to improving the quality of evidence-based care for youth who identify as TGD.

Citation:

Jason Rafferty (2018) Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics Sep 2018, e20182162; DOI: 10.1542/peds.2018-2162 (direct pdf)