Hormone Therapy in Transgender Children and Adolescents

Gender identity starts to form when kids are very young, like around 2 or 3 years old. At this age, they can recognize gender in themselves and others (Ruble et al., 2006). Gender dysphoria happens when someone feels distressed because their gender identity doesn’t match the sex they were assigned at birth. This can make it hard for them to function in their daily life.

There are specific criteria in a book called the Diagnostic and Statistical Manual of Mental Disorders that doctors use to diagnose gender dysphoria in children. To get this diagnosis, a child needs to meet at least 6 of the following criteria and have felt distressed or had trouble functioning for at least 6 months (APA, 2013).

The diagnostic criteria in children includes (APA, 2013):

1. Really wanting to be the other gender or believing that you are the other gender.
2. Liking to wear clothes that are usually worn by the opposite gender.
3. Preferring to pretend to be the opposite gender in games or make-believe.
4. Preferring to play with toys or do activities that are usually for the opposite gender.
5. Liking to have friends who are of the opposite gender.
6. Not liking toys, games, or activities that are usually for your own gender.
7. Disliking your own body’s sexual parts.
8. Wanting your body to have the sexual parts that match the gender you feel you are.

Is your child experiencing any of the above? Book your consultation with Ally Heart today.

Gender dysphoria might show up at different times during childhood, but for many kids, it doesn’t last into adulthood (Steensma et al., 2011). 

Taking care of transgender children and teenagers needs a team of different experts. These experts can include doctors who give hormones and mental health professionals. Before starting any treatment, transgender adolescents have to see a mental health expert first. Then, they might begin treatment to stop puberty (pubertal blockade) or get hormones that help them feel more like their gender (gender-affirming hormones). This helps them feel better about themselves and their bodies (Hembree et al., 2017; Coleman et al., 2012).

Suppressing Puberty:

Puberty starts when a part of the brain called the hypothalamus sends a signal called gonadotropin-releasing hormone (GnRH). This signal tells the pituitary gland to release two hormones: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). These hormones then go to the ovaries in girls and the testes in boys. In girls, they make the ovaries release estrogen, and in boys, they make the testes release testosterone. These hormones cause the changes in the body that happen during puberty. For some young people, their feelings of being uncomfortable with their gender, called gender dysphoria, stick around when they start going through puberty and might even get stronger (Steensma et al., 2011; Spack et al., 2012; deVries & Cohen-Kettenis, 2012).

The guidelines for treating gender dysphoria, like those from the Endocrine Society and the World Professional Association for Transgender Health (WPATH), say it’s okay to use puberty blockers for young people who are just starting puberty (Hembree et al., 2017; Coleman et al., 2012). This usually happens when they reach Tanner stage 2:

• For girls, this means breast development like raised nipples and bigger areolas.
• For boys, it’s when the penis and scrotum start growing and the testes reach a certain size (4 mL to 6 mL).

Studies have found that using puberty blockers using GnRH analogs can help transgender youth feel better emotionally (Cohen-Kettenis & van Goozen SH, 1998; de Vries et al., 2011). Blocking puberty gives them more time to explore their gender identity and live as the gender they identify with. If they start puberty blockers early, it can also prevent irreversible changes from happening during puberty, which can be helpful if they decide to take gender-affirming hormones later on (Spack et al., 2012; Hembree et al., 2017).

Puberty blockers are usually given as GnRH analogs, and common ones include goserelin, leuprolide, or histrelin. They have following risks and benefits:

You can take a consultation with our Doctors and Endocrinologist regarding puberty blockers on Ally Heart here.

Gender Affirmative Hormone Therapy:

Transgender adolescents who still feel gender dysphoria after puberty suppression can start taking hormones like estrogen or testosterone. This usually happens around age 16 when they can decide for themselves. These hormones help change their body to match their gender identity (Hembree et al., 2017; Coleman et al., 2012).

For transgender girls, estrogen is used to make their body more feminine. It can be taken as a pill, a patch, or an injection. Doctors prefer a type called 17b-estradiol because another type called ethinyl estradiol might cause blood clots (deep vein thrombosis) (Toorians et al., 2003).

For transgender boys, testosterone is used to make their body more masculine. It’s given as a shot into the muscle or under the skin. But there can be side effects sometimes, like too many red blood cells (erythrocytosis) (Hembree et al., 2017; Rosenthal, 2014; Spratt et al., 2017).

Those transgender teenagers who presents in late puberty, that is, Tanner Stage 4 or 5:

For girls:

• At Tanner stage 4, they have bigger breasts and nipples (secondary mount formed by papilla & areola).
• At Tanner stage 5, their breasts look more like an adult’s (areola part of breast contour & projecting nipples).

For boys:

• At Tanner stage 4, their penis and testes (12 mL to 15 mL) grow bigger, scrotum becomes dark.
• At Tanner stage 5, their penis and testes (greater than 15 mL) are fully grown.

These teens don’t need puberty suppression, although GnRH agonists may be prescribed to minimize the required dosage of hormones (Hembree et al., 2009). They may start taking prescribed hormones to match their gender, like testosterone for trans-boys or estrogen for trans-girls. Trans-girls might also need a medicine called spironolactone (antiandrogen treatment) to lower testosterone levels. It is a diuretic used for its antiandrogenic properties (Prior et al., 1989; Corvol et al., 1975).

At Ally Heart, we assist you in Gender Affirmative Hormone Therapy (GAHT) through our well-curated package.

REFERENCES:

• American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association; 2013.
• Cohen-Kettenis PT, van Goozen SH. Pubertal delay as an aid in diagnosis and treat ment of a transsexual adolescent. Eur Child Adolesc Psychiatry 1998;7(4):246–8. 
• Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of trans sexual, transgender and gender-nonconforming peple version 7. Int J Transgend 2012;13:165–232.
• Corvol P, Michaud A, Menard J, et al. Antiandrogenic effect of spirolactones: mechanism of action. Endocrinology 1975;97(1):52–8.
• deVries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in chil dren and adolescents: the Dutch approach. J Homosex 2012;59(3):301–20.
• de Vries AL, Steensma TD, Doreleijers TA, et al. Puberty suppression in adoles cents with gender identity disorder: a prospective follow-up study. J Sex Med 2011;8(8):2276–83.
• Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guide line. J Clin Endocrinol Metab 2009;94(9):3132–54.
• Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2017;102(11):3869–903. 
• Prior JC, Vigna YM, Watson D. Spironolactone with physiological female steroids for presurgical therapy of male-to-female transsexualism. Arch Sex Behav 1989; 18(1):49–57. 
• Rosenthal SM. Approach to the patient: transgender youth: endocrine consider ations. J Clin Endocrinol Metab 2014;99(12):4379–89.
• Ruble DN, Martin CL, Berenbaum SA. Gender development. In: Eisenberg N, ed itor. Handbook of child psychology. Social, emotional, and personality develop ment, vol. 3. Hoboken (NJ): John Wiley & Sons; 2006. p. 858–932.
• Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129(3):418–25.
• Spratt DI, Stewart II, Savage C, et al. Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: demonstration in female-to-male transgender patients. J Clin Endocrinol Metab 2017;102(7): 2349–55.
• Steensma TD, Biemond R, de Boer F, et al. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry 2011;16(4):499–516.
• Toorians AW, Thomassen MC, Zweegman S, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in trans sexual people. J Clin Endocrinol Metab 2003;88(12):5723–9.