Transgender patients: Providing sensitive care

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Applied Evidence

Transgender patients: Providing sensitive care

J Fam Pract. 2016 July;65(7):450-452,457-461

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References

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SIDEBAR
How to help transgender teens

Gender exploration is a normal part of childhood. Changes that occur during puberty cause many adolescents to question their ideas of gender and sexuality, but those with persistent gender nonconformity or extreme body dysphoria should receive medical and mental health care as early as possible.

A mental health professional (MHP) can help families create a safe, unconditionally accepting, and supportive environment in which their child can develop into his or her authentic self. A specialist in adolescent gender dysphoria (GD) should be consulted before initiating hormone therapy. Family physicians are well positioned to provide follow-up and ongoing care.

Initiating hormone suppression for adolescents with GD early in puberty can greatly reduce the emotional trauma, as well as the need for surgery related to unwanted secondary sex characteristics. Hormone suppression also gives adolescents more time to explore their gender nonconformity and developmental needs. Treatment with a gonadotropin-releasing hormone agonist such as leuprolide or histrelin can be initiated for adolescents in Tanner Stage 2, assessed by hormone levels, as well as breast, testicle, and pubic hair development (childgrowthfoundation.org/CMS/FILES/Puberty_and_the_Tanner_Stages.pdf), to suppress ongoing puberty.^11,14

The effects of puberty blockers are reversible. If preferred, however, medication management can allow teens to progress directly from hormone suppression to the puberty of their self-identified gender once initiation of adult transgender hormone therapy is started—typically around the age of 16.¹¹

Some adolescents may seek medical care well after puberty has begun. It is possible to use hormone suppression therapy after a teen has started to develop unwanted secondary sex characteristics. However, such patients may get less benefit from puberty blockers and often derive more benefit from initiation of cross-gender hormones.

Safety—a broader perspective. Regardless of medical treatment or the age at which treatment is begun, parents and patients need to be reminded that gender transition is about more than hormones. It is crucial that either the MHP or primary care physician, or both, address safety issues and work with the transgender individual to create a comprehensive plan for his or her health, safety, and social well-being.

Psychosocial concerns for transgender youth are vast, often encompassing rejection by peers and potentially, by family and authority figures; harassment; physical, emotional, and sexual abuse; inadequate housing; legal problems; lack of financial support; and educational difficulties.¹⁵ School is a particular source of concern. A survey by the Gay, Lesbian and Straight Education Network found, for instance, that nearly 9 in 10 transgender youth had been verbally harassed at school because of their gender expression. More than half also reported being physically harassed (eg, pushed or shoved).¹⁵

Bathroom use in schools is a major issue, as well, with transgender youth often prevented from using the restroom or locker room that coincides with their gender identity. In May, 11 states filed a lawsuit against the Obama administration for directing schools to allow such students to do so or risk the loss of federal funds.¹⁶

Tools and support. In 2006, the Vancouver Coastal Health, Transcend Transgender Support & Education Society, and the Canadian Rainbow Health Coalition published guidelines for the care of transgender adolescents, including a modification of the HEEADSSS tool (used to assess teens’ psychosocial well-being) specific to transgender youth.¹⁷ (See http://www.amsa.org/wp-content/uploads/2015/04/CaringForTransgenderAdolescents.pdf.) The tool can help you identify possible areas of concern and intervene, as needed.

If a patient reports feeling especially vulnerable at school, for example, encourage him or her to identify supportive friends, family members, teachers, or school counselors who can help create safe networks. Suggest that a teen who feels threatened travel in groups whenever possible. Stress to family members that their acceptance is key to nurturing positive feelings in youth with GD. And refer patients and parents to organizations that provide information and support.

Chief among them are Trans Youth Family Allies¹⁸ (www.imatyfa.org), which provides resources for parents, educators, and health care practitioners; the Human Rights Campaign, which has created a survival guide for gay and transgender youth who are forced to seek independent living¹⁹ (available at hrc-assets.s3-website-us-east-1.amazonaws.com//files/assets/resources/HRC-OnOurOwn-LGBTQYouth.pdf), and the Gay, Lesbian, Bisexual, and Transgender National Help Center, which hosts a GLBT national hotline (888-843-4564) and a weekly Trans Teen Online Talk Group.²⁰ For more information about the online talk group, go to glbthotline.org and click on “transteens.”