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Puberty blockers, cross-sex hormones: Canada’s family doctors get guidance on treating youth with “gender dysphoria”

Puberty blockers, cross-sex hormones: Canada’s family doctors get guidance on treating youth with “gender dysphoria”
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Canada’s family doctors are getting new guidance on how to manage the burgeoning number of teens identifying as transgender.

A new review article published Monday urges doctors to take a “thoughtful, affirming” approach and to avoid “influencing the adolescent to move down a path they would not have chosen for themselves.”

“The youth’s voice is always paramount,” the authors write in a special issue on transgender health appearing in this week’s edition of the Canadian Medical Association Journal.

A recent Canadian study found less than half of transgender youth are comfortable discussing their health care needs with their family doctor.

“Although the consensus in the medical community in the 1960s and 1970s was to view gender variance through a disease model in which associated behaviours, expression and declared identity were deemed pathological and in need of correction,” the authors write in the CMAJ, “the current approach is an affirming one that does not view gender variance as pathological.”

With wait lists at specialty gender clinics stretching a year or longer, the review offers family doctors advice on supporting the social and medical transitioning of teens with “gender dysphoria” — psychiatry’s label for the distress that may accompany the incongruence or mismatch between the gender one identifies with, and one’s gender “assigned” at birth.

The article provides recommendations on the timing of prescribing hormone blockers to suppress puberty as well as “cross-sex” hormones — estrogens so that a trans girl develops a more feminized figure and testosterone to give trans boys a more angular jaw and masculine physique.

The review comes as divorced parents fight complex and messy legal battles over who gets to decide the course of hormone treatments for their transgender teen, and as experts report more youth with no known histories of gender identity issues in the past suddenly identifying as transgender. A recent controversial study on so-called “ rapid-onset gender dysphoria” suggested “social and peer contagion” could be behind “cluster outbreaks” of gender dysphoria among friends, and that some teens (mostly trans boys, female to male) are being influenced by social media, including YouTube transitioning videos. The study, based on parental reports, has been attacked by transgender advocates as seriously methodologically flawed and is now being reviewed by the journal that published it.

It s also not uncommon to have youth who, a couple of weeks ago, decided that, after talking with a friend or researching on the Internet that maybe they re transgender.

However, the authors of the CMAJ article also note that the sex ratio of teens presenting to transgender clinics appears to be changing, “with many more youth who are assigned female gender at birth seeking care than those assigned male.”

The reason for the phenomenon isn’t clear.

On Saturday, the Post’s Douglas Quan reported that the number of referrals to the gender clinic at B.C. Children’s Hospital rose from seven in 2007, to 80 in 2017. The transgender clinic at Toronto’s Hospital for Sick Children sees over 200 referrals each year.

Dr. Joey Bonifacio, an adolescent medicine specialist at Toronto’s St. Michael’s Hospital and a co-author of the CMAJ review article, said the approach to care has moved away from a “Drop the Barbie” approach, “where it was deemed almost like you should ‘correct’ a child’s behaviour or a child’s identity.”

The youth s voice is always paramount

Instead, “The validating and affirming approach is an approach that gives you a bit of both of those, in the sense that you should address it, but maybe you shouldn’t try to correct it either, but see where the youth is and where the parents are, and working together as a team so that that youth is functioning well, both physically and mentally.”

Precise numbers in Canada are unknown, but studies from other countries suggest about one to four per cent of teens identify as a different gender from their birth gender.

It’s recommend hormone blockers be given only once puberty starts — on average, at age 10-and-a-half for children born female, and 11-and-a-half in those “assigned” male gender at birth. “Some youth find that their dysphoria abates as puberty starts, making it important to allow initial pubertal changes to occur,” the authors write.

However, the drugs can also buy youth time “to explore their gender identity and expression without having to worry about ongoing pubertal changes and development of secondary sexual characteristics that may be psychologically disturbing and undesired.”

We re not moving in one direction or another … I tell families that it allows you to take a deep breath, but a very long breath, so you have more time to figure stuff out and gather more information

The drugs are used to block the hormones that normally increase during puberty. For youth also struggling with mood and anxiety disorders, they can act as a pause button, Bonifacio said. “We’re not moving in one direction or another … I tell families that it allows you to take a deep breath, but a very long breath, so you have more time to figure stuff out and gather more information.”

The Endocrine Society, an international medical organization, says cross-sex or “gender-affirming” hormones may be administered around age 16, or as young as 13-and-a-half in special circumstances.

However, Bonifacio and his co-authors say “many youth understandably express the desire to go through puberty in their affirmed gender at similar ages to their peers, which would necessitate starting gender-affirming hormones at even younger ages.”

That troubles one leading U.S. expert, who worries that, without proper assessments by trained mental health experts, family doctors could be too quick to prescribe cross-sex hormones, which come with some irreversible body changes. Testosterone for female-to-male can cause a permanent deepening of the voice. Estrogen for male-to-female transitioning causes breast development.

Puberty blockers can be lifesavers for many transgender youth, said Dr. Laura Edwards-Leeper, a clinical psychologist who helped create the first hospital-based clinic in the U.S. for transgender youth at Boston Children’s Hospital in 2007.

“There are certainly youth who persist in their gender dysphoria,” she said. “But it’s also not uncommon to have youth who, a couple of weeks ago, decided that, after talking with a friend or researching on the Internet that maybe they’re transgender.”

Without a thorough mental health assessment, “the risk is that teens may be started on irreversible medical interventions that really aren’t appropriate, and they may later regret it.”

The CMAJ special edition also recommends doctors use medical forms and documents that include options other than “male” and “female” and that they address transgender youth in the name and pronoun they go by, including non-binary ones like “they” and “ze.” A growing number of youth are identifying with genders outside the male-female binary, the authors write, with many born female identifying as “transmasculine,” or a gender identity that is “not male” but also not female.

A B.C. case raises difficult questions about parental rights and about how young is too young to make medical decisions. The result is a messy ethical and legal tangle

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