Treatments for Gender Dysphoria in Transgender Youth

1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

1. KQ1: For children and adolescents who identify as transgender and have not initiated puberty, what are the benefits and harms of offering/prescribing pubertal suppression compared to not offering/prescribing pubertal suppression?

• Outcomes: Depression/anxiety, suicidality, distress/dysphoria, social interaction, quality of life (QoL), medication effects (weight gain, height, decreased secondary sex characteristics, hot flashes, headache, bone density, fertility)

2. KQ2: For adolescents who identify as transgender and have initiated puberty, what are the benefits and harms of prescribing medical affirmation with hormone therapy as compared to no intervention or social affirmation alone?

• Outcomes: Depression/anxiety, suicidality, distress/dysphoria, social interaction, QoL, estrogen effects (feminization, weight gain, mood swings, hot flashes, VTE, migraine, fertility, cancer risks), antiandrogen effects (feminization, hypotension, electrolyte abnormality, VTE), and androgens (masculinization, cancer risks, HTN, hyperlipidemia, vascular disease)

2. KQ3: For adolescents who identify as transgender and have initiated puberty, what are the benefits and harms of surgical affirmation as compared to no intervention or social affirmation without or without medical affirmation?

• Outcomes: Depression/anxiety, suicidality, distress/dysphoria, social interaction, QoL

2. Why are you struggling with this issue?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines gender dysphoria (GD) as a condition in which a person has a marked difference between the expressed or experienced gender and the biological sex at birth for at least six months. For children, the desire to be the other gender must be verbalized. Individuals with gender dysphoria have clinically significant impairment in social, occupational, or other important areas of functioning1. Transgender youth is defined as "subset of gender-diverse youth whose gender identity does not match their assigned sex and generally remains persistent, consistent, and insistent over time; the term "transgender" also encompasses many other labels individuals may use to refer to themselves2."

According to the Centers for Disease Control and Prevention (CDC), 1.8% of high school students identify as transgender3. Transgender youths have high rates of depression, anxiety, eating disorders, and substance use disorders4. Nearly half of transgender teenagers seriously considered suicide and 35% attempted suicide within the past year3. Adolescents who identify as transgender also face significant social stigma, violence, and victimization; 31% experienced sexual assault within the past 12 months and 24% were threated or injured with a weapon while at school3. 27% felt unsafe going to school and 35% report bullying3.

Gender-affirming health care is part of comprehensive primary care for many gender-diverse patients, and may include supportive behavioral health care, gender affirming hormones, puberty blockade, medical procedures, and surgical interventions. There is a lack of current evidence-based guidance for care of children and adolescents who identify as transgender, particularly regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation. While these are some existing guidelines and standards of care,2, 5-6 most are derived from expert opinion or have not been updated recently so a comprehensive evidence review is currently not available.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.
2. Rafferty J, AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Committee on Adolescence, AAP Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018;142(4): e20182162
3. Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students—19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep 2019;68:67–71. DOI:http://dx.doi.org/10.15585/mmwr.mm6803a3
4. Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics. 2018;141(5):e20173845. doi:10.1542/peds.2017-3845.
5. Coleman E, Bockting W, Botzer M, et al. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender-nonconforming people. 2012. 7th version. www.wpath.org
6. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Center of Excellence for Transgender Health Department of Family & Community Medicine University of California, San Francisco. 2016. 2nd edition.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

The AAFP is interested in a comprehensive evidence review to facilitate the development of a clinical practice guideline for family physicians to provide high value and appropriate care of the child and adolescent who identifies as transgender. Improvement in outcomes for these youth, particularly in mental health and safety, will demonstrate improvement in this area.

4. When do you need the evidence report?

Saturday, January 1, 2022

5. What will you do with the evidence report?

The evidence from the systematic review will be used to inform recommendations for a clinical practice guideline from AAFP. Our timeline is flexible.

(Optional) About You

What is your role or perspective? Professional Society

If you are you making a suggestion on behalf of an organization, please state the name of the organization: American Academy of Family Physicians

May we contact you if we have questions about your nomination? Yes