We Are all Responsible for Transgender Care

Medical management of gender-diverse youth has evolved greatly in the past 20 years, following the development of gonadotropin-releasing hormone (GnRH) analogues for pubertal suppression in central precocious puberty (1). In this approach, pioneered in the Netherlands (also called the affirmative model), provision of early pubertal suppression with GnRH analogues affords a gender-diverse young person the time to consider their gender experience before the development of secondary sex characteristics through: (1) initiation of gender-affirming sex hormones, or (2) discontinuation of the GnRH analogue to allow natal puberty to progress (2). This practice has been codified into the World Professional Association for Transgender Health Standards of Care and the Endocrine Society guidelines (3, 4). An excellent overview of the available pharmacologic management of gender-diverse youth is presented by O’Connell et al (5) and speaks more specifically to the implementation of these guidelines.

Offering gender-affirming services to young people is not without controversy, with recent legislative actions and court cases resulting in prohibitions (and reinstatement) of these therapies before the age of majority in several jurisdictions (6). Underlying these bans is the misconception that in offering puberty suppression to a young person, the medical system begins to shepherd them toward a series of increasing medical interventions. In this framework, the inertia of providing gender services to youth intensifies into late adolescence and adulthood with inevitable subsequent gender-affirming sex hormone therapy and/or surgical interventions. This false belief renders any clinician into an agent of this forward-moving system, and the GnRH analogue into a gateway drug of sorts. However, while most adolescents pursuing puberty suppression will go on to pursue sex hormone therapy to affirm their gender identity, not all will do so. Additionally, nonintervention by withholding puberty suppression is a misnomer: Withholding suppression is de facto an intervention toward an unwanted natal puberty with effects reverberating into the young person’s future, whereby a cisgender body is unwillingly foisted on them. Ethicists have wrestled with this subject and direct us to consider why our system has created more safeguards (or roadblocks) to a transgender life path than a cisgender life path, if we are to perceive them as equal in legitimacy (7).

Offering gender services to a young person requires timely intervention, as early puberty is the actionable moment to “pause” natal secondary sex characteristics. While availability of multidisciplinary gender services with this “Dutch approach” is increasing, there remain substantial barriers for youth to access care (GnRH analogues can be cost prohibitive and not universally available, and long wait lists are a common complaint in our practice and many others). As a result, there have been calls to broaden furnishing of gender care services from tertiary care centers to pediatric primary care providers to reduce these barriers, among other reforms (8). It is evident that systems-wide changes, including the expansion of clinicians willing to provide gender-affirming care to gender-diverse youth, will be necessary if we are to meet their clinical needs with the alacrity they deserve.

As the urgency for providing gender-affirming care to youth grows, so does the need for high-quality research. The long-term effects of GnRH analogue therapy and gender-affirming sex hormone therapy in young people present enormous areas of clinical interest, and our knowledge still growing. At present, we believe the long-term effects of GnRH analogue therapy to be minimal compared to the irreversible (or difficult-to-reverse) secondary sex changes from an unwanted natal puberty, but there is much that we do not yet know, as the use of GnRH analogues for this population is relatively new. Ongoing research seeks to elucidate the late effects of GnRH analogue therapy on bone density, cognition, fertility, and other measures. Additionally, our field is developing a nuanced understanding of how to implement gender-affirming sex hormone therapy beginning in adolescence, but guidance for implementation and monitoring of sex hormonal interventions is still rooted in expert recommendations. We must learn more about optimal sex hormone therapy management, including ways to assess our interventions with patient-centered outcomes measures.

At present, however, more gender diverse youth are seeking medical expertise than ever before, and we as clinicians will doubtlessly encounter them and need to care for them. The review from O’Connell et al (5) allows us to consider our current gender-affirming care paradigm and controversies therein. It is our duty as clinicians to meet our young transgender patients where they are, to offer the evidence-based care we have, and to be forward-thinking as we continue to develop care guidance.

Glossary

Abbreviation

GnRH

gonadotropin-releasing hormone

Additional Information

Disclosures: The authors have nothing to disclose.

Data Availability

Data sharing is not applicable to this article because no data sets were generated or analyzed during the present study.