Guidelines for Pubertal Suspension and Gender Reassignment for Transgender Adolescents

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Diagnosis and Decision to Treat

GID3 may appear at any age; its manifestations may be subtle or extreme and they are usually well articulated. Behavioral manifestations and ideation vary widely and should be evaluated by a mental health professional. Because GID desists in most, change of gender designation in school or other social circumstances is rarely appropriate during childhood and psychological evaluation is helpful.

A diagnosis of persistent GID is required for consideration of suppression of puberty. This diagnosis

Initiation of GnRH Analog Treatment

After confirmation of the recommendation for pubertal suppression, the endocrinologist must confirm the good health of the adolescent, explain the reason for the use of GnRH analogs, and, subsequently, sex steroids, review the possible adverse effects,5 and present the treatment plan and follow-up required. Tanner staging should be confirmed by physical examination and hormone levels. Hormones must be measured in a clinical laboratory that maintains assays that have sufficient precision and

GnRHa

GnRH analog treatment completely suppresses pituitary gonadotropins and, thereby, secretion of the gonadal sex steroids responsible for body changes that have occurred before treatment. The normal adrenal gland produces low levels of testosterone in genetic men and women,16 the amount of which are insufficient to cause androgenic effects. However, rare genetic abnormalities of adrenal steroid production that result in excess testosterone and, even more rarely, excess estrogen should be

Decision to Treat: Puberty Suppression

Treatment of adolescents with GID is not recommended before Tanner stage 2 of puberty. Only mental health professionals experienced both in the evaluation and management of children and adolescents with GID and trained in child and adolescent developmental psychopathology should make the recommendation to suppress puberty.5 Adolescents treated with suppression of puberty, followed by sex steroid replacement, maintain their GID and demonstrate improved psychological function.8 This is in

Future Genital Surgery in MtF Adolescents

The skin of the penis and scrotum are used in the construction of a vagina and labia during genital surgery for transsexual women (MtF).5 The amount of male genital tissue available at Tanner stage 2 is limited and may alter the techniques required for genital reconstruction at age 18. Surgeons have published good results in adolescents following puberty suppression and estrogen administration at age 16.18

Summary

The recommendation that pubertal suppression at Tanner stage 2 be considered in adolescents with persistent GID is based on the increase in gender dysphoria and harmful behavior if not treated, the improved psychological functioning during suppression, no change of mind in terms of gender identity, and, in a smaller number who completed sex steroid treatment and surgery, disappearance of dysphoria regarding gender.18 The ease and safety of long-term GnRHa administration and of hormone

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    Of those that did not have pubertal suppression treatment (N=50), 91% went on to have the IMF mastectomy, and only 1% required no surgical intervention.14 To start GnRHa children must meet WPATH criteria, which includes achieving Tanner stage 2 (breast buds for AFAB), having an increase in dysphoria upon achieving onset of pubertal development, having social support, and having a required diagnostic evaluation by a skilled mental health provider to assess if DSM-5 criteria are met.10,15 GnRHa formulations include leuprolide acetate (Lupron) as a 1-month or 3-month injection, triptorelin acetate (Trelstar) as a 3 or 6 month injection, and histrelin acetate (Vantas, Supprelin LA) as a subcutaneous implant.

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    From studies investigating their use in central precocious puberty, GnRHa are believed to reversibly suspend pubertal development without long-term impairment of fertility [7,8]. However, most TGD youths do not cease GnRHa before commencing gender-affirming hormones, and no empirical data exist examining long-term fertility outcomes for this population [1–3,5,27,28]. Therefore, counseling regarding FP is recommended to be conducted before the initiation of GnRHa [1,2].

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    Pubertal suppression with GnRHa is used starting as early as Tanner stage 2. This is a reversible treatment used to prevent the development of permanent secondary sex characteristics and alleviate the psychological distress associated with these changes.27 However, GnRHa administration also pauses gonadal maturation.28

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