Puberty Suppression Research Articles

Timing of puberty suppression in transgender adolescents and sexual functioning after vaginoplasty.

Sexual function in transgender adolescents after puberty suppression has been a topic of recent clinical and scientific questions. This study aimed to explore the long-term effects of early treatment with puberty suppression on sexual functioning of transfeminine individuals after vaginoplasty. This retrospective cohort study included 37 transfeminine individuals treated with a gonadotropin-releasing hormone agonist (puberty suppression), estrogen, and vaginoplasty (penile inversion technique or intestinal vaginoplasty) at the Center of Expertise on Gender Dysphoria in Amsterdam, the Netherlands, between 2000 and 2016. Experiences regarding sexual functioning and difficulties were assessed with a self-developed questionnaire ~1.5years after genital gender-affirming surgery and compared between early (Tanner stage G2-3) and late (Tanner stage G4-5) treatment with puberty suppression. Following surgery, 91% of transfeminine individuals was able to experience sexual desire, 86% experienced arousal, and 78% could attain an orgasm. Seventy-five percent of transfeminine individuals who had not experienced an orgasm pre-surgery were able to experience one post-surgery. Of all participants, 62% reported having tried penile-vaginal intercourse post-surgery. The majority reported the presence of one or multiple sexual challenges. There were no significant differences in postoperative sexual function or sexual difficulties between groups treated with early versus late puberty suppression. With these findings, more adequate and tailored information on the expected effects of early endocrine gender-affirming treatment (including puberty suppression) can be given by healthcare professionals. This is the first study that has assessed sexual functioning of transgender individuals treated with puberty suppression, and has differentiated between the pubertal stage at treatment initiation. Limitations were the small cohort size and retrospective study design. This study focuses on sexual functioning, however, it is important to realize sexual wellbeing is multifactorial and encompasses more than genital functioning or the ability to have certain sexual experiences. This study found that post-vaginoplasty transfeminine individuals after both early and late suppression of puberty have the ability to experience sexual desire and arousal, and to achieve orgasms. Outcomes are comparable to previous findings in those who started treatment in adulthood.

Levels of Satisfaction and Regret With Gender-Affirming Medical Care in Adolescence

There is a need to improve the evidence base for gender-affirming medical care provided to adolescents, including the experiences of those who have received this care. To examine rates of satisfaction, regret, and continuity of care in adolescents who received puberty blockers and/or gender-affirming hormones as part of gender-affirming medical care. This survey study used the 2023 online survey wave of an ongoing longitudinal study, the Trans Youth Project, among a community-based sample of transgender youth and their parents initially recruited throughout the US and Canada between 2013 and 2017. The satisfaction and regret data include responses from a youth or their parent representing 87% of the youth aged 12 years or older in the cohort who have received gender-affirming medical care (235 of 269 youths). Of these, 220 completed the 2023 survey (main sample); information about continuity of care was available for all youth. Data analysis was performed from April to August 2024. Satisfaction, regret, and continuity of care following puberty blockers or suppression and/or gender-affirming hormones. Self- or parent-reported satisfaction or regret with gender-affirming care and continuation of care. Among the 220 youths in the main sample (mean [SD] age, 16.07 [2.40] years; 30 [14%] multiracial, non-Hispanic; 18 [8%] White, Hispanic; 155 [70%] White, non-Hispanic; 17 [8%] other race and ethnicity, including Asian, Black [Hispanic and non-Hispanic], Hispanic with unknown race, multiracial Hispanic, or Native American; gender at last interaction: 68 [31%] boys, 132 [60%] girls, 20 [9%] gender diverse, eg, nonbinary) and their parents, very high levels of satisfaction and low levels of regret with puberty blockers and gender-affirming hormones as well as high levels of continuation of care were reported. Of these 220 respondents in the main sample, 9 were regretful of having received blockers (n = 8) and/or hormones (n = 3; 2 of these individuals reported regret with both), of whom 4 have stopped all gender-affirming medical care and 1 has continued to receive blockers but plans to stop. The 4 others have continued care, suggesting that regret is not synonymous with stopping care. The findings suggest that youth accessing puberty blockers and hormones as part of gender-affirming care tend to be satisfied with and not regretful of that care several years later. While regret was rare, these experiences need to be better understood.

The natural course of bone mineral density in transgender youth before medical treatment; a cross sectional study.

Bone mineral density (BMD) Z-scores decrease during puberty suppression in transgender youth. Assessment of treatment impact has been based on the assumption that without intervention, BMD Z-scores remain stable. However, the natural course of BMD in this population is unknown. Retrospective cross-sectional study. Dual-energy X-ray absorptiometry scans prior to medical intervention were included from 333 individuals assigned male at birth (AMAB) and 556 individuals assigned female at birth (AFAB) aged 12-25 years. The relationship between age and BMD Z-scores of sex assigned at birth was analysed for the lumbar spine (LS), total hip (TH), femoral neck (FN), and total-body-less-head (TBLH), adjusted for height SDS, height-adjusted lean mass Z-score, and whole body percentage fat Z-score. In individuals AMAB, the BMD Z-score was negatively associated with age between 12 and 22 years: LS -0.13/year (95% confidence interval, CI -0.17; -0.10); TH -0.05/year (95% CI -0.08; -0.02); FN -0.06/year (95% CI -0.10; -0.03); and TBLH -0.12/year (95% CI -0.15; -0.09). Adjusting for height-adjusted lean mass Z-score attenuated the association at the LS and TBLH and eliminated the association at the TH and FN. BMD Z-scores and age were not associated between 22 and 25 years. In individuals AFAB, BMD Z-scores were only associated with age at the TBLH (-0.08/year, 95% CI -0.12; -0.04) between age 12 and 20 years. In individuals AMAB aged 12-22 years prior to any treatment, BMD Z-scores were inversely correlated with age. This could imply that BMD increases less in individuals AMAB than in the general population, and that changes in Z-score during puberty suppression and subsequent hormone supplementation are not necessarily due to treatment, but possibly related to lifestyle factors.

The experience of transfeminine adolescents and their parents regarding fertility preservation via testicular sperm extraction (TESE): a qualitative study.

How do transfeminine adolescents and their parents experience fertility preservation via testicular sperm extraction (TESE)? Participants experienced the TESE process positively when provided with appropriate guidance to navigate the decisional dilemma between preserving future biological parenthood and the pressure to start puberty suppression early. Sperm banking through ejaculation is not feasible for all transfeminine adolescents due to genital dysphoria and early puberty; for this group, TESE is the only alternative. However, during early puberty, they must postpone or pause puberty suppression until spermatogenesis is fully developed. All consecutive TESE patients in our centre and their parents were invited to participate. Between December 2022 and May 2023, we included 6 adolescents and 10 parents. We used a qualitative approach based on semi-structured interviews to study the experience of the transfeminine adolescents and their parents. Transfeminine adolescents diagnosed with gender dysphoria in early puberty (Tanner stage ≥2) who underwent TESE before the start of puberty suppression or gender-affirming hormones participated in this study. The interviews were recorded, manually transcribed and analysed using reflective thematic analysis focusing on understanding the participants' experiences of puberty and fertility preservation and the various factors and social processes influencing their decision to undergo TESE. Transfeminine adolescents decide to undergo invasive fertility preservation because of a possible, future desire for parenthood. Parents stressed the importance of preventing future decisional regret. They both saw masturbation to obtain a semen sample as unreachable. Even though TESE is a surgical procedure with possible complications and pain afterwards, this alternative seemed less dysphoric to them.Adolescents had to postpone the start of puberty suppression, waiting for spermatogenesis to complete. Given the unpredictable development of puberty, they felt a lot of stress and anxiety during this period and were primarily concerned about the lowering of their voice. Because of this puberty-related stress, they were constantly balancing their motivations for fertility preservation against the early start of puberty suppression to prevent unwanted irreversible pubertal body changes. To support this decisional dilemma, adolescents and their parents need adequate communication with each other and their healthcare providers to reflect on their stress for pubertal change. Furthermore, close, continuous surveillance of their current mental state by their parents, together with their psychologist and pubertal development by their physicians, is needed. Despite the challenging decision and postponement of puberty suppression, they retrospectively experienced it positively without any regret. All adolescents successfully underwent TESE, with viable spermatozoa obtained and without complications. This may result in a more positive reflective experience regarding fertility preservation. Furthermore, the perspectives of adolescents with the intention of TESE but who already started with puberty suppression before the preservation were not included. This study helps healthcare providers improve their counselling and guidance of transfeminine adolescents who consider postponing puberty suppression for fertility preservation via TESE. The adolescents and their parents know more clearly what to expect during fertility preservation. Specific peer-support programs may facilitate the decision process for upcoming adolescents. No external funding was used for this study. None of the authors have any conflicts of interest. Not applicable.

Variations in volume; Breast size in trans women in relation to timing of testosterone suppression.

Breast development is an important outcome for trans women receiving gender affirming hormone therapy (GAHT). Limited breast development has been reported, possibly because of testosterone exposure during puberty. The impact of puberty suppression (PS) on breast development is unclear. To investigate the impact of PS and timing of PS prior to GAHT on breast volume and satisfaction. Cross-sectional study. Tertiary gender identity clinic. 60 trans women (aged 17-57 years) after 4.5±1.7 years of GAHT were included of whom 23 initiated PS early in puberty (Tanner stage G2-3), 17 late in puberty (Tanner stage G4-5), and 20 started GAHT in adulthood without prior PS. Breast volume measured with a 3D scanner and breast satisfaction measured with a questionnaire. Comparisons of breast volumes were adjusted for fat percentage. Median breast volume was 115ml (IQR 68; 203), i.e. bra cup-size <A. Breast volume was 47ml (95%CI -9; 104) larger in the late PS group compared to early PS but this difference was only 4ml (95%CI -67; 75) after correction for fat percentage. Breast volume in the adult group was comparable to the early and late PS groups (adult vs. early PS 27 ml (95% CI -28; 83) and adult vs. late PS -20 ml (95% CI -80; 40)). In total, 68% of subjects were satisfied with breast size (57% of early PS, 76% of late PS and 70% of adult group). Early start of PS was not associated with larger breast volume, suggesting that pubertal testosterone exposure does not affect breast volume after subsequent GAHT. Despite limited breast size, most trans women were satisfied with their breast development.

Shaping the skeleton: impact of GnRH analogue and sex hormone therapy on skeletal dimensions in transgender individuals.

Skeletal dimensions vary between sexes. Men typically have broader shoulders and women a wider pelvis. If gender affirming hormone therapy (GAHT) with or without prior puberty suppression (PS) alters these dimensions in transgender individuals remains unclear. To investigate impact of PS and GAHT on skeletal dimensions. Retrospective cross-sectional study. Gender identity clinic. Transgender individuals assigned male at birth (AMAB) and assigned female at birth (AFAB) who underwent dual-energy X-ray absorptiometry (DXA) scanning between ages 18 and 28 years were divided into four groups: Early PS (Tanner G/B2-3)+GAHT, Late PS (Tanner G/B4-5)+GAHT, GAHT only, and Untreated. Shoulder and pelvis dimensions measured by DXA scan were compared between groups, with adjustment for height. A total of 121 individuals AMAB and 122 AFAB were included. Only in individuals AMAB who underwent early PS had smaller shoulders compared to untreated individuals AMAB (-1.3 cm; 95%CI -2.1; -0.5). In individuals AMAB from both the early and late PS group, pelvic inlet, pubic symphysis width and interischial distance were greater compared to untreated individuals AMAB resulting in dimensions comparable to untreated individuals AFAB. Only in early PS AFAB pelvic inlet width was smaller compared to untreated individuals AFAB (-1.0 cm; 95%CI -1.5; -0.6), and comparable to untreated individuals AMAB. The study results suggest that skeletal dimensions are only altered by GAHT if endogenous puberty has not yet been completed at start of PS. These findings enhance our understanding of hormonal effects on the skeleton and may hold clinical relevance for body image as well as for forensic anthropology. Future research should evaluate clinical implications for surgical or obstetrical outcomes in transgender individuals.

Abdominal imaging in precocious puberty in girls: can imaging determine onset of puberty?

Precocious puberty in girls is defined by the appearance of secondary sex characteristics before the age of 8 years. Precocious puberty is either peripheral or central. In most cases, the cause of central precocious puberty is unknown. Rapidly progressive forms of central precocious puberty may benefit from puberty suppression to prevent compromised final height and psychosocial problems related to the physical changes. Idiopathic central precocious puberty in girls can be a challenging diagnosis. Clinical examination, evaluation of growth charts, bone age, and hormonal tests are part of the workup. The role of pelvic ultrasound to evaluate pubertal features of the internal genitalia in this context is controversial. In this paper, we havereviewed the literature to find the scientific bases for several proposed ultrasound parameters and cutoff values for the determination of onset of puberty in girls with suspected central precocious puberty. There are no reliable cutoffs for the measurements of uterus and ovaries for the diagnosis of central precocious puberty and there is overlap in the appearance of the organs in both prepubertal and pubertal girls. The interpretation of the findings on pelvic ultrasound must be done with caution and always in close communication with the referring clinicians.

Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications.

Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.

Determinants of Bone Mass Accrual in Transgender and Gender Diverse Youth Undergoing Pubertal Suppression Therapy

Introduction/Background: Gender-affirming care for gender diverse and transgender (GDTG) youth includes puberty suppression with gonadotropin-releasing hormone agonists (GnRHa). Puberty is a critical period of bone mass accrual, and pubertal suppression may impact bone health. Previous studies have shown a decrease in areal bone mineral density (aBMD) Z-score while on puberty suppression. However, the rate of bone mass accrual and its determinants during GnRHa therapy are not known.Methodology: This is a retrospective chart review of GDTG youth with aBMD assessment within six months of starting GnRHa monotherapy at Cincinnati Children's Hospital Medical Center between 01/2011 and 12/2022. In individuals with follow-up aBMD assessment, we calculated their aBMD velocity and generated Z-scores using reference data from the Bone Mineral Density in Childhood Study. The determinants of baseline height-adjusted aBMD and aBMD velocity Z-scores were assessed with multiple linear regression models.Results: Thirty-six participants (36% assigned female at birth (AFAB), mean age at first aBMD assessment 12 ± 1.1 years) had baseline height-adjusted aBMD Z-score of -0.053 ± 0.79. Among 16 participants with follow-up aBMD assessment, the mean aBMD velocity Z-score was -0.42 ± 1.13 (-0.27 ± 0.79 in AFAB vs -0.52 ± 1.32 in assigned male at birth, p = 0.965). Baseline aBMD Z-scores significantly correlated with age at the first aBMD assessment (adjusted R2 0.124, p = 0.02) with combined modeling including age at first aBMD assessment and BMI Z-score being most significant (adjusted R2 0.21, p = 0.008). Only BMI Z-scores were positively associated with the aBMD-velocity Z-scores (adjusted R2 0.255, p = 0.046).Conclusions: GDTG youth undergoing GnRHa therapy appeared to have below-average aBMD velocity Z-scores. A lower BMI Z-score was a determinant of lower baseline height-adjusted aBMD and aBMD velocity Z-scores. Building on previous studies, our study highlights aBMD velocity as a novel technique for bone health surveillance in GDTG youth.

Functional Changes to Achilles Tendon and Enthesis in a Mouse Model of an Adolescent Masculine Gender-Affirming Hormone Treatment.

Many transgender youth seek gender affirming care, such as puberty suppression, to prolong decision-making and to align their physical sex characteristics with their gender identity. During peripubertal growth, connective tissues such as tendon rapidly adapt to applied mechanical loads (e.g., exercise) yet if and how tendon adaptation is influenced by sex and gender affirming hormone therapy during growth remains unknown. The goal of this study was to understand the how pubertal suppression influences the structural and functional properties of the Achilles tendon using an established mouse model of transmasculine gender affirming hormone therapy. C57BL/6N female-born mice were assigned to experimental groups to mimic gender-affirming hormone therapy in human adolescents, and treatment was initiated prior to the onset of puberty (at postnatal day 26, P26). Experimental groups included controls and mice serially treated with gonadotropin release hormone analogue (GnRHa), delayed Testosterone (T), or GnRHa followed by T. We found that puberty suppression using GnRHa, with and without T, improved the overall tendon load capacity in female-born mice. Treatment with T resulted in an increase in the maximum load that tendon can withstand before failure. Additionally, we found that GnRHa, but not T, treatment resulted in a significant increase in cell density at the Achilles enthesis.

Effects of puberty suppression on bone, body composition, handgrip strength and glucolipid profile in early-pubertal transgender adolescents

Introduction The effects of puberty suppression for more than 2 years before the start of gender-affirming hormones (GAH) on bone mass acquisition and body composition are understudied. Materials and methods Retrospective study on 46 transgender adolescents (20 trans boys and 26 trans girls) receiving a gonadotropin-releasing hormone analogue (GnRHa) from Tanner stage 2-3, followed by GAH around the age of 16 years. At start of GnRHa and at start of GAH, dual-energy X-ray absorptiometry (DXA) at lumbar spine (LS), femoral neck (FN) and total body (TB), handgrip strength test and fasting blood sampling were performed. Z-scores were calculated using reference values for both cis girls and cis boys. Results GnRHa were administered for a median of 3.2 years (± 0.69) in trans boys and 2.7 years (± 1.05) in trans girls. Bone mineral apparent density (BMAD)-LS Z-scores decreased significantly in both trans boys and trans girls, while BMAD-FN Z-scores decreased only in trans boys. Fat% and Fat Mass Index Z-scores significantly increased in both groups, while Lean Mass Index Z-scores significantly decreased. Handgrip strength Z-scores for the sex registered at birth (SRAB) remained stable in trans boys while they decreased in trans girls. There was no significant influence of the treatment on either insulin sensitivity or lipid profile. Discussion GnRHa administration for more than two years during the physiological time of puberty decreases bone mass acquisition, mainly at the lumbar spine and induces a general increase in fat mass. Although lean mass acquisition is undermined in both groups, handgrip strength is affected mainly in trans girls compared with age-matched peers for the SRAB.

Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service.

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Growth and Adult Height Attainment in Danish Transgender Adolescents Treated With GnRH Analog and Sex Hormones.

Endogenous sex steroids influence the pubertal growth spurt and adult height. However, the impact of puberty suppression and sex steroids on growth in transgender adolescents is sparsely studied. We investigated pubertal growth, serum IGF-I and IGF binding protein-3 (IGFBP-3), and adult height of transgender adolescents receiving hormone therapy. Observational study of a national cohort (2016-2023) comprising 219 transgender adolescents <18 years of age. Treatment consisted of gonadotropin-releasing hormone agonist combined with estradiol or testosterone (adjusted to serum concentrations between 0 and +2 SDs corresponding to the gender identity). Adult height was within ±2 SD for sex assigned at birth.Most trans girls reached adult height within references of girls. For trans girls (bone age ≤15 years before treatment), a growth spurt was observed during estradiol therapy. IGF-I and height SD score (SDS) declined during oral estradiol administration (-0.13 SDS per month, P = .059, and -0.02 SDS, P = .001, respectively). We observed significantly lower adult height compared to target height for trans girls (-2.7 cm, P = .01) and significant differences between height SDS before treatment and at adult height (-0.35 SDS, P < .001).Half of the trans boys remained short (<-2 SD) compared to references for boys, and most completed growth spurt before initiation of treatment. IGFBP-3 declined following testosterone treatment. There was a significant difference between height SDS before treatment and at adult height (-0.17 SDS, P < .001). The minor reduction in adult height of trans girls after hormone treatment may be beneficial to some, whereas trans boys did not experience height gain.

Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review

BackgroundTreatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a...

Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review

BackgroundClinical guidelines outline the use of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria or incongruence. Robust evidence concerning risks and benefits is lacking. There is a need to aggregate...

Puberty Suppression for Pediatric Gender Dysphoria and the Child’s Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of “the child’s right to an open future,” which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort

Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking. To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting. This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022. Reidentification with birth-registered sex. The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received. Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%). These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

Puberty suppression of children with gender dysphoria: Urgent call for research.

Puberty suppression of children with gender dysphoria: Urgent call for research.

101. Experiences of Transgender Youth With Puberty Suppression in a Pediatric Hospital-Based Gender Clinic: A Qualitative Study

101. Experiences of Transgender Youth With Puberty Suppression in a Pediatric Hospital-Based Gender Clinic: A Qualitative Study

Gender-affirming mastectomy in transmasculine individuals in The Netherlands: a large cohort study on outcomes and trends

Introduction: Gender-affirming mastectomy is frequently performed in transmasculine individuals. The aim of this study is to describe surgical and demographic trends and outcomes in a large group of individuals undergoing this procedure. Materials and methods: All individuals who underwent gender-affirming mastectomy from 01-1990 to 01-2023 in our center were identified. A retrospective chart study was conducted, recording medical history, use of medication including hormones, puberty suppression, surgical history, preoperative chest characteristics, BMI at surgery, surgical technique, concurrent surgical procedures, resection weight, complications and re-operations. Procedural, demographic and surgical trends were analyzed. Results: A total of 2030 individuals were included of whom 1350 (67%) underwent double incision, 551 (27%) donut, 67 (3%) peri-areolar, 55 (3%) batwing and 7 (<1%) another mastectomy technique. A steep increase of performed mastectomies was observed in recent years. The mean age of people undergoing this procedure is increasingly lower. Surgical trend analysis showed: an increase in the use of the double incision technique, a smaller chest was deemed eligible for donut mastectomy and a less frequent use of a pedicled nipple-areolar complex. Postoperative bleeding that required a reoperation under general anesthesia occurred in 142 (7.0%) individuals (6.3% after double incision, 7.1% after donut, 14.9% after peri-areolar and 12.8% following batwing mastectomy). One or multiple surgical corrections were performed in 19.9% after double incision, 31.2% after donut, 14.9% after peri-areolar and 32.7% following batwing mastectomy. The median clinical follow-up time was 3.2 years (IQR 0.6-6.4). Discussion: The frequency of performed mastectomy procedures has increased drastically over recent years. Specific surgical and demographic trends were identified.