Pubertal Suppression for Transgender Youth: A Right to an Open Future Approach in Support of a Youth-Empowered Legal Framework.

LGBTQ youth mental health during COVID-19: unmet needs in public health and policy

Gender-Affirming Hormone Therapy Linked to Better MH in Trans Youth

Both in the United States and Europe, the number of minors who present at transgender healthcare services before the onset of puberty is rapidly expanding. Many of those who will have persistent gender dysphoria at the onset of puberty will pursue long-term puberty suppression before reaching the appropriate age to start using gender-affirming hormones. Exposure to pubertal sex steroids is thus significantly deferred in these individuals. Puberty is a critical period for bone development: increasing concentrations of estrogens and androgens (directly or after aromatization to estrogens) promote progressive bone growth and mineralization and induce sexually dimorphic skeletal changes. As a consequence, safety concerns regarding bone development and increased future fracture risk in transgender youth have been raised. We here review published data on bone development in transgender adolescents, focusing in particular on differences in age and pubertal stage at the start of puberty suppression, chosen strategy to block puberty progression, duration of puberty suppression, and the timing of re-evaluation after estradiol or testosterone administration. Results consistently indicate a negative impact of long-term puberty suppression on bone mineral density, especially at the lumbar spine, which is only partially restored after sex steroid administration. Trans girls are more vulnerable than trans boys for compromised bone health. Behavioral health measures that can promote bone mineralization, such as weight-bearing exercise and calcium and vitamin D supplementation, are strongly recommended in transgender youth, during the phase of puberty suppression and thereafter.

Introduction: It is not known whether the extent of pubertal development influences the treatment effects in very young transgender people undergoing puberty suppression (PS) and gender-affirming hormone therapy (GAHT). This study aimed to investigate how anthropometric parameters and body composition change according to birth-assigned sex and affirmed gender during PS and GAHT. Methods: This retrospective study included data from 201 adolescents starting PS under 15 year at a national gender service (139 trans boys and 62 trans girls). Data from 127 of them who subsequently received GAHT were available. Height, weight, BMI, total FM, fat, and muscle mass (LM, FM, and MM) were collected using Tanita body composition analyzer. Results: “In puberty” trans boys (Tanner stage 2–3), total FM increased on PS (2.49 kg, 95% CI: 1.66; 3.33) similarly to LM (2.41 kg, 95% CI: 1.85; 2.97), while in “completing puberty” trans boys (Tanner stage 4–5) the increase of total FM (1.80 kg, 95% CI: 1.21; 2.39) was higher than total LM (0.97 kg, 95% CI: 0.63; 1.30). “In puberty” trans boys showed increasing mean FM z-scores from baseline after 3 years of PS (from 0.70 to 1.2). Mean LM z-scores decreased in both “in puberty” (from 0.98 to 0.5) and “completing puberty” (from 1.16 to 0.80) trans boys. During GAHT, “in puberty” trans boys showed a greater increase of total LM and MM (respectively, 6.28 kg, 95% CI: 3.54; 9.02 and 6.08 kg, 95% CI: 3.64; 8.51). Both groups “in puberty” and “completing puberty” trans boys did not show a further increase in total FM. In contrast, “completing puberty” trans girls showed the greatest increase of total FM during PS (4.27 kg, 95% CI: 1.50; 7.03). MM and LM % decreased throughout PS in all trans girls, whereas body composition only changed slightly during GAHT. Conclusions: The effect of PS on body composition is more pronounced in “in puberty” trans adolescents, and “in puberty” trans boys are more responsive to GAHT, showing greater increases in MM and LM. In trans girls, the most significant increase in FM, along with reduction in LM and MM, occurs during PS, whereas no substantial changes were observed during subsequent GAHT. This suggests that any effect on physical performance may depend on pubertal development at the start of intervention.

“No One Stays Just on Blockers Forever”: Clinicians’ Divergent Views and Practices Regarding Puberty Suppression for Nonbinary Young People

Parents of trans and gender-diverse youth can experience challenges navigating gender-affirming (GA) care such as stigma, transphobia, and lack of support. There is little information available about stressors, worries, and positive feelings of parents as they try to support their youth accessing GA care. This article presents baseline survey data on experiences and stressors of 160 parents/caregivers in the Trans Youth CAN! cohort study, which examined medical, social, and family outcomes in youth age 16 years or younger considering puberty blockers or GA hormones. Data were collected at 10 Canadian gender clinics. Authors report on participating parents' characteristics, levels of support toward youth, stressors, worries, concerns, and positive feelings related to youth's gender. Most parent participants were White (85.1 percent), female (85.1 percent), birth or adoptive parents (96.1 percent), and reported strong support for youth's gender. Participants' concerns included their youth facing rejection (81.9 percent), generalized transphobia (74.6 percent), or encountering violence (76.4 percent). Parents also reported positive feelings about seeing their youth grow more confident. Most parental worries and stressors were situated outside the family, reflecting the systemic discrimination faced by youth and their families. Social workers could address these by developing systems-focused interventions and by further taking into account intersectional health disparities.

Mental Health during Medical Transition in a US and Canadian Sample of Early Socially Transitioned Transgender Youth

Transgender youth have been found to experience mental health disparities, experiencing greater rates of depression and anxiety than their cisgender counterparts. This mixed-methods study examined social support and how it is related to well-being and resilience among transgender youth. A sample of 154 transgender and gender nonbinary youth (13 to 21 years) completed a survey at a Pride event in a Midwest US city. The survey assessed living as one’s affirmed gender, social support, finding meaning in life, quality of life, mental health, and resilience. A focus group (n = 8) discussed their experiences of support. Ninety-two percent reported being assigned female at birth; 27% identified as transmasculine, 38% genderqueer, and 24% more than one gender. Family support was positively associated with the likelihood of living as one’s affirmed gender. Support from friends and significant others were not significant indicators of living as one’s affirmed gender. Participants with greater family support were less likely to report that they had a mental health problem in the past year. Friend support was positively associated with connectedness and finding meaning in life. Qualitative analyses identified how transgender youth define and experience support in their lives. Future studies should examine the use of family counseling and building communication skills for transgender youth health and resilience interventions.

Purpose: Since May 2021, numerous state legislatures in the United States have introduced bills to restrict the participation of transgender and gender diverse (trans) youth in gender-segregated sports in a manner consistent with their gender identity. The purpose of this study was to understand how medical providers of pediatric gender-affirming care for trans youth view these legislative efforts and how they believe these bills will affect their practice and patients. Methods: In March 2021, we recruited participants using listservs known to be frequented by providers of gender-affirming medical care to complete a survey about bills that restrict trans youths' participation in sex-segregated sports. Eligible participants were over the age of 18, currently worked as a physician, nurse practitioner, or physician's assistant, and provided gender-affirming care to trans youth under the age of 18 in the United States. Results: We analyzed the responses of 103 providers from all 50 states and the District of Columbia. Most participants identified as White (77%), cisgender women (70%), and specialized in pediatric care (52%). The most salient theme, described by nearly all participants, was that legislation banning trans youth from sports participation would lead to worsening discrimination and stigmatization. Other themes included worsening mental and physical health of trans youth, forced changes to clinical practice, politicization of trans youth, and efforts required to stop these bills. Conclusions: Providers of gender-affirming care in this study overwhelmingly opposed legislation that bans trans youth from sports participation citing the severe consequences to the well-being of trans youth. More research is needed to examine stakeholder's opinions regarding legislation that does not ban but otherwise restricts sports participation by trans youth.

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17 years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.

Improving Our Understanding of Medical Decision-Making Competence in Puberty Suppression.

Health care and mental wellbeing in the transgender and gender-diverse Chinese population

Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. Time since enrollment and receipt of PBs or GAHs. Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51). This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Content warning: this Article discusses suicidality. For transgender and some nonbinary youth, living under a chosen name is a first step toward becoming their authentic selves. For these youth, a name change is powerful; it allows them to choose a name that matches their gender identity. They consider their birth name to be a distressing “dead” name—one that they cannot relate to and need to bury. Using one’s chosen name decreases suicidality among transgender youth who face many challenges, including family rejection and other severe mental health stressors. Transgender and nonbinary youth can only require others to use their chosen names after obtaining a legal name change. But only two states in the nation currently allow minors to change their name legally without their parents’ consent and active assistance. Parental consent requirements are problematic because youth whose parents do not support their gender identity must wait, exposed to harm and distress. Thus, we deny them this first step towards correcting their gender and the accompanying mental health relief—delaying youth who have otherwise transitioned years before adulthood. In the meantime, with identification cards that do not match their gender identity, transgender and nonbinary youth are at risk of discrimination and other harm. They may drop out of school and avoid seeking employment for fear of bias and rejection. Our laws must change to protect our transgender and nonbinary youth by allowing them to change their legal name independently. Their mental health and well-being depend on these crucial reforms.

The World Professional Association for Transgender Health (WPATH) defines gender dysphoria as "Discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)" (WPATH, 2016). Gender creative (GC) and transgender (TG) youth are at high risk for severe mental health disparities if they don't receive competent and timely gender transitioning care. Although awareness and early care of TG youth in specialty clinics is improving and increasing, there is still much effort that is required to eliminate barriers to care at many levels and thus improve outcomes. Nurses, particularly advanced practice nurses, are poised to lead the way in creating safe, inclusive, family centered spaces for TG and GC children, youth and their families as well as acting as vital mentors for other nurses. The purpose of this paper is to discuss the increasing prevalence of GC and TG youth, the significance of inclusive care for GC and TG youth, treatment guidelines, and the impact parents and advanced practice nurses can have on the journey of these youth as they explore and find their place on the gender spectrum.