13 - Care for the Transgender Adolescent

Dr. Susan Kaufman and Dr. Yossie Ahmadieh, an adolescent medicine doctor with Physicians for Reproductive Health, explore the vital topic of gender-affirming care for transgender and gender-diverse adolescents, discussing how appropriate medical interventions can be life-saving for these vulnerable youth.

Outline

• Introduction to Transgender Healthcare Basics
• Barriers and Mental Health Considerations
• Creating Safe Spaces in Clinical Settings
• Puberty Blockers and Treatment Options
• Gender-Affirming Hormone Therapy Approaches
• Monitoring Testosterone Therapy
• Estrogen Therapy and Anti-Androgens
• Surgical Options and Cancer Screening

Reference

NASPAG Essentials of Pediatric and Adolescent Gynecology: Chapter 3

Help us with education research! Please fill out this 4-question survey so we can gather unidentified data on who our podcast is reaching!

What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

Want to test your knowledge?
PAG WebEd cases are a great way to review our podcast content.

Chapters

• 0:48 Patient Case: Teen Seeking Gender Care
• 1:43 Introduction to Transgender Healthcare Basics
• 4:59 Barriers and Mental Health Considerations
• 9:36 Creating Safe Spaces in Clinical Settings
• 12:36 Puberty Blockers and Treatment Options
• 16:53 Gender-Affirming Hormone Therapy Approaches
• 20:38 Monitoring Testosterone Therapy
• 25:32 Estrogen Therapy and Anti-Androgens
• 29:18 Surgical Options and Cancer Screening
• 32:02 Closing Thoughts and Provider Empowerment

Transcript

Yossie Ahmadieh: 0:24

So a 13-year-old assigned female at birth adolescent comes into your clinic with their mom. The adolescent identified as male and wants to discuss medication to stop his period, which is causing him a great deal of stress and depression. What evaluation is needed, if any, and what topics should be discussed regarding menses medication, fertility and etc. Menses medication, fertility and etc.

Susan Kaufman: 0:48

Hi everyone and welcome to PAG Over Pastries, a 20 to 30 minute review podcast regarding all the topics in pediatric and adolescent gynecology. I'm Susan Kaufman, a pediatric and adolescent gynecologist at Virtua Health in South Jersey.

Yossie Ahmadieh: 1:10

Hi everyone. I'm Yossi Amadie. I'm an adolescent medicine physician and an advocate with Physicians for Reproductive Health. I use she her pronouns.

Susan Kaufman: 1:17

And today we're going to be talking about care for the transgender and gender diverse adolescent. So our references today are Chapter 3, Care of the Transgender and Gender-Diverse Adolescent by Jason Jarin and Frances Grimstad in the Essentials of Pediatric and Adolescent Gynecology that was released last year by NASPAC, as well as some additional resources from WPATH, the Endocrine Society and the UCSF Guidelines. So, Yasi, what's your favorite pastry?

Yossie Ahmadieh: 1:51

My favorite pastry is almond croissant.

Susan Kaufman: 1:54

My main favorite is chocolate croissants. Okay, so let's get started. So, starting with some basic information, about 1.4% of 13 to 17-year-olds in the United States will identify as transgender, and 1.3% of 18 to 24-year-olds will identify as the same. The number is less in the adult population at 0.5%. However, these statistics may not be accurate because it depends on who's collecting them and how long they've been collecting them for. What are some of the things that transgender youth are at risk for, and why do we care about treating them?

Yossie Ahmadieh: 2:41

We have a great deal of evidence that adolescents who identify as LGBTQ, and especially transgender. They're at higher risk of high-risk behaviors, including suicidal thoughts, suicidal ideations, suicidal attempts, and we know that gender-affirming care in general is a life-saving treatment for our patients. For example, if a patient is diagnosed with diabetes, we prescribe insulin for them. The same thing is that gender affirming care is a medication, a treatment for our patient to make sure that they grow up physically and mentally healthy and they will be a productive part of the society.

Susan Kaufman: 3:25

Absolutely, and I have seen such transformation in my adolescent patients who initially and frequently come in very depressed. A lot of times they're not even going to school and they're not participating in any activities. They may have had previous suicide attempts and once they feel seen and heard and start to get some treatment whatever that treatment is that they choose their whole personality and their whole life changes, and so it's just really rewarding to be able to see that change person and it is really hard for some of us to actually think about our gender and sexuality, because our gender and sexuality is accepted in the society and just imagine if it wasn't.

Yossie Ahmadieh: 4:17

So that's really like what I focus on when I guide families through this treatment.

Yossie Ahmadieh: 4:42

Right, and I'm sure you've had experiences where you have had parents that they are comfortable to accept some risk as other medication could have. These medication also have a risk that parents need to accept and basically I want to try to bring the parent and the patient together and see how we can be supportive so patient can survive, can be, you know, through themselves, and also parents can be there and support them through this transition. Sometimes parents really need time. Some parents, definitely they they're going through a grief process and you know they lost a child, basically, and they want to go through like mourning for that child and then they get to a level of like accepting their new child. And I just want to everyone like providers, parents, patients know that we are not here to only do hormone therapy or like refer them to surgeries. We're really here for families, to educate them, because there are a lot of misconceptions about these medications and this care outside of medical field. So we want to make sure we educate them, give them enough information so they make educated decision.

Susan Kaufman: 5:59

Absolutely and hopefully, once they get to our office, both the patient and the family feels like they're in a safe, protected environment and the family feels like they're in a safe, protected environment.

Susan Kaufman: 6:09

And there are other barriers besides family concerns to these patients getting care. So there may be legal barriers, depending on where someone lives. There may be a lack of providers to provide this care. There may be social barriers if the child has not come out to their family or their friends or relatives. There may be fear on the part of the child or teenager or family about confiding in the medical system because they don't know what's going to happen if they come in and honestly talk about why they're there to see us. So it's important to establish a safe environment for these folks to be able to open up and get whatever care it is that they're seeking. Teens and adults who identify as transgender or gender diverse face additional challenges than the ones you just listed, challenges than the ones you just listed, including discrimination in education and housing, employment, insurance, and may even be subject to violence by people in their surroundings. How can we help people to feel comfortable when they come into our office?

Yossie Ahmadieh: 7:33

Yes, that's a very good question. I actually like make sure that my colleagues and the residents that I teach they do this for everyone, not only trans patients. I want them to ask, and I usually ask patients about the name that they want me to address them with and also the pronouns, and I also normalize it with saying my name and also my pronouns. So I do that for all patients to just get used to. Like this is a normal thing that I how I introduce myself to everyone. The other things that we can do as provider is like wearing a pin or like our MA is having a pin that says their pronouns. Those are also very comforting and affirming.

Susan Kaufman: 8:07

Right, sometimes we're the first people that they come out to, when we have private time with our patients and we're talking to them about other things that may be bothering them. So when we're taking a history on our patients, like you said, we're going to ask about pronouns, we'll likely ask about gender identity, but it depends on whether we ask them with their parent present or by themselves. We'll ask about their history of gender exploration, ask about whether they are engaging in any transitional activities, such as coming out, dressing in their identified gender, changing their name and so forth, and also what their gender-related goals are. Because no matter how someone identifies, everybody's goals are different and everybody approaches how they want to affirm themselves differently. So we also have to make sure we don't have any biases about oh, these people are going to do it this way, and that's another affirming point on our part to realize that and to communicate that to our patients that we understand that we're going to help them with however they want to affirm their identity.

Yossie Ahmadieh: 9:26

And that's really good point, dr Kaufman. Providers could assume the you know method of treatment or like how we recommend the treatment, but really this care is about how you want to affirm that patient's goals. You know. Gender affirming care includes hormone therapy, includes adjunct therapies, includes surgeries right? Not everyone wants all the procedures or like all the hormone therapy. It really depends on, like how patient visions the gender journey that they have.

Susan Kaufman: 9:58

Right, exactly, so what are some of the things that we go through as we're counseling them?

Yossie Ahmadieh: 10:04

I really emphasize on discussing these topics not only with us, but also with a mental health provider. We do need mental health providers support not only before have also discussed the topics that they discuss with us and they go to more details on how it's going to affect them socially, mentally, physically or their future plans. Obviously, we want to make sure they have a discussion regarding fertility and fertility preservation because that, with the hormone therapy and some surgeries, can affect that their ability to have biological children in future. I do want to make sure, like I'm going over gender dysphoria and how it's affecting life and what are the other aspects that come after we start gender affirming care, so, for example, exploring their sexuality. Sometimes there would be a lot of other trauma that could come up from past because we're giving them some mental space with decreasing gender dysphoria. So I want them to be as ready as they can be and they need to have enough support to go through these stages of transition. We want to help them how to come out to other people, other members of family.

Susan Kaufman: 11:32

Right, absolutely so, no matter what they decide to do regarding their gender affirmation. The mental health therapy is so important, and sometimes they need family therapy as well. And then I find that sometimes all they're looking for is to stop their periods, because a lot of their gender dysphoria comes from menstruating. So that's one beginning aspect. Another one is when we see younger children, teens that have not gone through puberty or just beginning to go through puberty, and they're coming in seeking treatment. So what do we do for those young folks?

Yossie Ahmadieh: 12:12

Based on like guidelines that we have and evidences that we have, we really don't do anything until they meet certain criterias and especially for younger folks, we do provide a lot of counseling.

Yossie Ahmadieh: 12:26

And if they are reaching almost 10 or two. We start discussions about puberty suppressions with medications that we have available and we have had available to treat, for example, precocious puberty in the past. So these are not new medications, it's just we are using them now in transgender care. So that's like one option that we can offer people when they get to Tanner stage two. So for assigned female at birth, that's when they develop breast bud and breast tissue. For assigned male at birth is when the testicular size gets to four cc or above.

Yossie Ahmadieh: 13:05

If people are far into their puberty, we're probably not going to use the puberty blockers. We have other medications for that at that point. But basically puberty blockers are GnRH analog. So basically we put a pause on puberty and then they have more time to actually explore their gender and make sure that this is, like you know, the gender that they want to be and like figure out their goals as well. So I look at it as a pause, not a permanent change. So as soon as they stop the puberty blocker, all the effects will be reversible so they can go through puberty. We do have some concern about impact of it on bone density. However. We are obtaining dex size scans, usually at baseline and then every year after that, to make sure that the bone density does not decline significantly to a point that we are worried about fractures and other complications that can come from that. And again, if they stop it the bone density will go back. And if they want to transition to a hormone in future, build up the bone density with that hormones.

Susan Kaufman: 14:23

Right, and I love the fact that it gives people time, it gives the patients time, it gives family time to really sort out what's going on. So what about when we want to start gender affirming hormone therapy, whether we've just stopped periods or we've used puberty blockers, and now this young person wants to begin gender affirming hormone therapy?

Yossie Ahmadieh: 14:47

At that point usually we evaluate our patient, their readiness, and that could be from mental health aspect, from physical health aspect and also show a social health aspect. I want to make sure, like I set up my patient for success, so I want to make sure all the mental health problems are under control and not saying that a patient cannot have anxiety, should not have depression before starting the hormones. And then this is the hot topic these days what age would you start? A teenager?

Susan Kaufman: 15:22

What are the current guidelines?

Yossie Ahmadieh: 15:24

Yes, and unfortunately we do not have a lot of research. Hopefully there are research and the evidences will come out. As of now, we have just a Dutch approach model that says we can start pubertal suppression at age of 12 and the gender-affirming hormone therapy at age of 16 and then surgical interventions at age of 18. In general, this is the guideline that has been there. But, however you know, based on like all these studies that come out and like say how life-saving this treatment is for our teenagers, the medical providers will decide when to start based on their evaluation, the mental health provider evaluation. This might be earlier age and obviously not too early to that point that we're putting patient at risk. You want also to make sure that the patients who've been persistent and consistent with their gender, they also go through puberty as their peers, right. So like if someone is identifying as transmasculine, so you want to actually make sure that they are going through puberty as other assigned male at birth. So that's important for social and mental health of someone who is trans.

Susan Kaufman: 16:43

Yeah, I really think that having a mental health provider involved is so important. Although the WPATH recommendations have changed. They used to require a letter from a mental health provider stating that this person was ready to go through gender-affirming care. Now the letter is not required but, as you stress, in adolescence, I think it's extremely important to make sure they're connected with mental health support and therapy.

Yossie Ahmadieh: 17:15

The new version actually recommends that a multidisciplinary team should have a letter.

Susan Kaufman: 17:20

I have been mostly in the private practice realm for years doing gender affirming care and I established relationships with therapists in my community that were specifically trained in gender affirming care so that we could work together to provide the right care, even though we weren't exactly in the same physical space or same academic space. So what are some of the discussions we want to have with patients before we actually write that prescription for testosterone or estrogen?

Yossie Ahmadieh: 17:59

there is any provider that prescribes hormone therapy in the first session that they meet patients. We all get to know our patients. First talk about the patient's concerns and also the parents' concerns, so that part of the discussion is very, very important. You give the fact, the medical evidence, to the parents so they understand the risk and benefits. Personally, I do a consent visit as a separate meeting after I did my evaluation and again I'll be in close contact with mental health providers in general, as you said, dr Kaufman, and then I'll go through changes that we're going to see with the start of testosterone or estrogen.

Yossie Ahmadieh: 18:36

I do go through the expectation when they are actually going to happen. I do explain that this is a second puberty. Other things that I go over. I talk about side effects, for example, like testosterone and estrogen can put you at high risk of hyper dyslipidemia, or like diabetes, or testosterone puts you at higher risk of acne. And then I do talk about fertility in detail. Recommend you know to preserve their egg or do the sperm banking before starting. We might not know a lot about fertility at this point, but this is like what the recommendation comes from and make sure if they are opting out of that choice. Then they understand what are the consequences at this point that we know of. I also have discussion regarding cancer screening and also social safety and knowing their own right.

Susan Kaufman: 19:30

Absolutely, and I also have a discussion about what are their goals. I want them to be able to clearly define their goals for me in terms of physical changes, so that we know what they want to accomplish and where we're heading, and in terms of side effects. I also talk with especially with testosterone about hair loss, because some of them may experience balding. Of course, we go through the laboratory changes that can occur with both testosterone and estrogen. So when we start testosterone therapy, we can give that as injections, both IM and sub-Q, as patches and gels and pellets. I think more commonly we're using sub-Q injections and maybe the gels, and so I counsel them about the pros and cons of each of those and determine what their preferences are. If they're going to go with an injection, then we have a whole session on how to draw up the medication and how to give an injection properly to prevent complications. If they're going with the gels, we have to counsel them about touching other people after they put the gel on and how to administer the gel and so forth.

Susan Kaufman: 20:46

I haven't had any teenagers opt for pellets. I think that's more in the adult realm. But have you used pellets?

Yossie Ahmadieh: 20:54

No, I actually use mostly sub-Q injections and also gels. You know they're cost-effective and easy accessibility with insurance.

Susan Kaufman: 21:04

So we start usually at 25 milligrams per week with a sub-Q injection and then the general guidance is to increase the dose between three and six months. I base that on what the patient wants to accomplish. If we're titrating the dose up, we'll end up somewhere between 50 and 100 milligrams on a weekly basis, and that will result in a blood level of 400 to 700 nanograms.

Yossie Ahmadieh: 21:32

My approach is similar to you For younger adolescents. We try to start as low as like 20 milligram and I think that's the lowest dose and then kind of like the increments that we go up would be slower compared to older adolescents. I usually start adolescents on 30 milligram weekly and go up.

Susan Kaufman: 21:51

I do follow blood levels, but I tend to titrate my doses more to the clinical changes than an actual blood level.

Yossie Ahmadieh: 21:59

And I've had patients who got deepening of voice that they were like, oh, we're done, we just were looking for the deepening of voice, so we're good. Like the other thing that I pay attention in increasing the dose of testosterone, I look at their hemoglobin. It's because testosterone increases red blood cell productions and can cause a stroke in future if it's too high. Sometimes I actually tell patients to do a phlebotomy. They go and donate blood and there is a protocol for trans people.

Susan Kaufman: 22:28

We're going to monitor lab work. I do it every three to four months for the first year and I measure an LH, fsh, estradiol level, testosterone, a CBC. I also get a lipid profile and then after a year. If they're stable, I'll do it every six months for a year and then, if they're stable on their dose and they're not having side effects or laboratory changes, I might go out monitoring them yearly, depending on any other medical comorbidities. We're watching their lipid panel. We're looking for any signs of hypertension, development of acne, hair loss or weight gain from that medication.

Yossie Ahmadieh: 23:09

Sometimes, you know, we overlap the menstrual suppression medications. Usually I use norethindrone or agestin and we kind of overlap.

Susan Kaufman: 23:19

I always want to start them out on menstrual suppression first, because I find that if I just start testosterone they get you know, all kinds of crazy irregular bleeding. So I prefer to convince them to be on some progesterone to start with and then take them off if they don't want to be on it and just use it as needed if they have breakthrough bleeding. But we also have to make sure they understand that testosterone is not a contraceptive and if they're having vaginal penetrative intercourse with a male partner, then we must counsel them about some form of birth control. And it doesn't have to be hormonal. It can be a Paragard IUD, it could be a barrier method. We have to make sure that they are on a contraceptive because testosterone can cause birth defects if they were to get pregnant.

Yossie Ahmadieh: 24:12

Yes, and I'm so glad that you brought the IUDs. We could have our own biases the IUDs. We could have our own biases, assumptions as providers and think transgender people do not like IUDs because of like the nature of placement. However, you know I've had multiple transgender patients who I placed IUD for them and to suppress their menses and also having a birth control to prevent pregnancy. So it is very important to counsel them Nexpol, non-iuds, progesterone-only pills, depo injection. So I think it's worth going through every option and again they will decide if they can deal with the procedure or the side effects.

Susan Kaufman: 24:55

Right, as well as STI counseling and prevention. So we have to remember to include that in our care for everybody. And what about for our transgender women and estrogen therapy?

Yossie Ahmadieh: 25:08

or thrombi or stroke, any history of hypertension, any history of breast cancer, any vaping nicotine use in general in our population and then having a migraine with aura. Because those are basically the big contraindications and I would say I've had patients who had blood disorders that would cause thrombi. We started them on estrogen. However, we collaborate with the hematology colleagues to make sure that we're on appropriate medications and we're monitoring estrogen. It's in the form of a pill or patches. There are subcutaneous injections as well. Usually I use the subcutaneous injection for older teenagers and young adults. With oral, I usually start about One milligram. Again, if patients are very sensitive or parents have concern about mental health being on hormones and complications with mental health, I can start on 0.5. However, one milligram is a good dose to start and I usually increase it with like about one to two milligram every three months. You can also do it every three to six months and highest dose for oral is somewhere four to six milligram daily. With the transdermal patches we usually start at 0.05 or 0.1 milligram and titrate that are based on like how patient tolerates it to 0.4 milligram per day. The goal blood levels of estradiol is 100 to 200. And usually that's like I let patients know. This is our goal. But again, if you see physical changes, you want to stay at the dose that you are and we're not even in the goal range. That's totally okay and usually you see breast growth, fat distribution and they store more fat in their hips and thighs. Also, we see some decrease in facial and body hair.

Yossie Ahmadieh: 27:13

Other medication that I use for trans women is anti-androgens. Basically I call them peripheral testosterone blockers because they are not going to totally stop the production of testosterone. However, they are going to decrease the effect of it and, in some cases, actually suppress the testosterone or decrease the level of it to some point. Sparalactone is one medication that we usually use. Just remember that the side effects are hyperkalemia and dizziness. So make sure your patients don't have dizziness at baseline. I usually for teenagers because they don't drink enough water. I usually start them on 25 twice a day or 50 milligram twice a day and we can go up to even 300 milligram. However, I experienced patients feel a lot of side effects at that dose. So 200 milligram per day would be a good dose. We also want to check testosterone levels and the goal for testosterone level to be 50 or below.

Susan Kaufman: 28:17

I find that a lot of my patients, maybe because of their age, are not as interested in gender affirming surgeries as they are in starting hormone therapy. But the gender-affirming surgeries that are available include facial surgery, sometimes some neck contouring, chest surgery, either mastectomies or breast implants, and then various forms of genital surgery. And I feel like most of the genital surgery is carried out in older individuals, not really in teenagers. I have had teenagers go through chest masculinizing surgery. Even my non-binary teens, when they reach about 17 or 18, have had that surgery. Oh, and of course 17 or 18, have had that surgery and of course, hysterectomy, plus or minus removing the ovaries. Others keep their ovaries if they have any thoughts about having genetic children in the future through a surrogate or through a partner who carries the egg.

Yossie Ahmadieh: 29:22

Yes and WPATH. In the new guideline they recommended patients to be on hormone therapy for a year and then decide about some of these surgeries Everywhere in the country. The age that they do those surgeries are different and depends on the practice, the surgeons and, again, these surgeries are also life-saving for our patients. We are trying to make sure we balance basically the risk of surgery and also the benefits of it.

Susan Kaufman: 29:53

And then you mentioned earlier about cancer screening. So as our patients get older, we have to remember that they should have the same type of preventative healthcare and preventative cancer screenings as anyone else. And that, of course, is going to end up depending on body parts at the time they need to begin their cancer screening. For instance, somebody who has had chest mask analyzing surgery may still be at risk for breast cancer and therefore could be screened with an ultrasound. And, of course, if somebody still has a cervix, we want to counsel them about pap smears. We want to talk about HPV vaccines, screening for prostate cancer in our older trans female patients and, of course, prep in our younger patients Well, actually, in anybody younger patients Well, actually in anybody.

Yossie Ahmadieh: 30:50

You know. I want to make sure that all the providers feel comfortable with just affirming patients right. Your trans patients are not different from your other patients and I want to make sure I empower the providers to do as little as they can to affirm their transgender patients like any other patients obviously, in their practice. Use their name, their pronouns also, just be like the safest space and if you feel that this is not aligned with your own beliefs, you should direct that patient to someone else that can provide better care and like more affirming care for the patient. I look at my job as just educating parents, educating my patient and be a moderator so they can meet in the middle.

Susan Kaufman: 31:36

Absolutely. Those are such important points. Okay, well, thank you so much for doing this podcast with me, and this concludes our podcast on transgender care for adolescents. Visit our PAG over pastries page on NASBAG website. It will include a transcript of this podcast and all our other podcasts that we've posted so far, with links to the references. You'll also find a survey that we would love people to fill out to find out who is listening and what is your background. Love people to fill out to find out who is listening and what is your background and if.