“Emerge”ing Insights into Health Care for Transgender Adolescents

It’s this not knowing
When the guest will leave
And you are the guest.

This is how poet Ali Blythe begins Transition in his new collection, Hymnswitch. Nonbinary and transgender youth may find that they too feel like guests in their own bodies. In addition to the normal stresses of adolescence, these youth may have distress because of a mismatch between their bodies and gender identity, known as gender dysphoria. The effects are concretely tangible: multiple studies, including one from the Centers for Disease Control and Prevention, demonstrate that adolescent gender minorities are two to three times more likely to 1) attempt suicide and 2) experience homelessness and substance abuse. They also face systemic discrimination — multiple states are considering legislation to block access to gender affirming care for transgender youth.

The long-term health effects of gender dysphoria are of huge concern to health care providers, including those at The Johns Hopkins Hospital who care for transgender adolescents at the Emerge Gender and Sexuality Clinic for Children, Adolescents and Young Adults. The Emerge team at Johns Hopkins Children’s Center is comprised of two adolescent medicine specialists, Renata Sanders and Errol Fields, along with clinical psychologist Kathryn Van Eck, nurse coordinator Kathy Tomaszewski and social worker Tisha James. The Emerge team knows well from its interactions with patients that puberty is often a distressing time for gender minorities. Says Fields, “There is often a lot of anxiety about the effects of puberty and how much those effects will negatively impact their physical appearance and experiences. For an example, having a period can be particularly distressing for a trans boy because that experience is often inconsistent with his male gender identity. Similarly, waking with a morning erection can be equally distressing for a trans girl.”

Transgender adolescents are also more likely to have suicidal thoughts than cisgender youth. In the transgender community, suicidal thoughts are more likely to develop among people who are under significant chronic stress, those who are bullied and people who face other stigmatization. A recent survey of transgender young adults shed some light on how to lower suicidal among gender minorities. The study, published by Jack Turban et al. in the January 2020 issue of Pediatrics, uses data collected by the National Center for Transgender Equality. Results showed that transgender adults who reported access to a treatment called puberty blockade as adolescents were less likely overall to have had suicidal thoughts during their lifetime than those without access to the treatment in their youth, even when adjusting for a wide range of demographic variables including familial support for their affirmed gender. “For this study,” according to Turban, “we felt it was important to examine only those who ever desired pubertal suppression, as an individual’s gender-related care is highly personal, and not all individuals desire pubertal suppression.”

Despite these findings, puberty blockade, a process in which a medication effectively “pauses” puberty for youth questioning their gender, remains a contentious issue. The rationale for this reversible treatment is to prevent development of unwanted secondary sex characteristics while giving youth more time to explore their gender identity. Critics of puberty blockade argue that we do not know all of its long-term effects, and that many children who experience gender dysphoria do not continue to report those symptoms after puberty. Critics also suggest that simply supporting children in their gender identities is enough until they are of the age (16 or 18, depending on local laws) to legally consent to gender affirming treatment. Endocrine Society guidelines recommend initiating pubertal blockers for adolescents after the onset of puberty, because their emotional reactions to these first physical changes have diagnostic value in establishing the persistence of gender dysphoria/gender incongruence.

However, in concordance with Turban’s findings, the World Professional Association for Transgender Health (WPATH) indicates that withholding gender affirming medical care until legal adulthood may prolong gender dysphoria and contribute to an appearance that could provoke bullying and victimization. The rationale for puberty blockade is to reversibly prevent the development of unwanted secondary sex characteristics while giving youth more time to explore their gender identity.

For WPATH and doctors who follow its treatment guidelines, a combination of puberty blockade and gender affirming hormones is an appropriate treatment for children who have gender dysphoria that is particularly intense or that intensifies at puberty. It is important to remember that puberty blockade is a reversible treatment, and gender affirming hormones and gender affirmation surgery are generally not offered to youth under age 16 or 18.

The Emerge clinic, which follows WPATH standards of care, sees a range of patients from age 6 to 25, has been open since summer 2017, although its members have worked with transgender adolescents for longer. “Generally speaking, we have noticed an improvement in the mental health of our patients after beginning gender affirming medical care,” Fields says. “Many continue to deal with stressors related to how others treat and react to their gender identity. Even so, their emotional lives appear significantly improved. We get that feedback from their parents, too.”

Transgender medicine and mental health is an evolving field with a need for ongoing research to learn how to provide the best care for gender minority youth. This clinic may very well be offering patients a lifeline.

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