EXPLANATION: What medical treatments do transgender youth receive?

Transgender medical treatment for children and adolescents is increasingly under attack in many states, labeled as child abuse and subject to criminalizing prohibitions. But it has been available in the United States for over a decade and is endorsed by major medical associations.

Many clinics use treatment plans developed in Amsterdam 30 years ago, according to a recent review by the British Psych Bulletin. Since 2005, the number of young people referred to gender clinics has increased tenfold in the United States, United Kingdom, Canada and Finland, according to the study.

The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormonal disorders, both have guidelines for such treatment. Here is an overview of what is usually involved.

PUBERTY BLOCKERS

Children who constantly wonder about the sex they were assigned at birth are often referred to specialist clinics offering gender confirmation care. This care typically begins with a psychological assessment to determine if children are suffering from “gender dysphoria” or distress caused when a person’s gender identity does not match a person’s assigned sex.

Children who meet clinical guidelines are first offered drugs that temporarily block puberty. This treatment is designed for young people diagnosed with gender dysphoria who have been counseled with their families and who are mature enough to understand what the diet entails.

The drug is not started until the young show early signs of puberty – enlargement of the breasts or testicles. This usually happens between the ages of 8 and 13 for girls and a year or two later for boys.

The drugs, known as GnRH agonists, prevent the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, a rare medical condition that causes an abnormally early onset of puberty.

The drugs can be given as injections every few months or as arm implants that can last up to a year or two. Their effects are reversible: puberty and sexual development resume as soon as the drugs are stopped.

Some children stay there for several years. A possible side effect: they can cause a decrease in bone density that reverses when the drugs are stopped.

HORMONES

After puberty blockers, children can either go through puberty while identifying as the opposite sex, or begin treatment to make their bodies more closely match their gender identity.

For those choosing the second option, the guidelines say the next step is to take manufactured versions of estrogen or testosterone – hormones that promote sexual development at puberty. Estrogen comes in the form of skin patches and pills. Testosterone treatment usually involves weekly injections.

Guidelines recommend starting them when children are mature enough to make informed medical decisions. That’s usually around age 16, and parental consent is usually required, said Dr. Gina Sequiera, co-director of Seattle Children’s Hospital Gender Clinic.

Many transgender patients take the hormones for life, although some changes persist if the drugs are stopped.

In girls transitioning to boys, testosterone usually causes a permanent lowering of the voice, facial hair and protrusion of the Adam’s apple, said Dr. Stephanie Roberts, specialist in the gender management service of the Boston Children’s Hospital. For boys transitioning to girls, estrogen-induced breast development is usually permanent, Roberts said.

Research on long-term hormone use in transgender adults has revealed potential health risks, including blood clots and changes in cholesterol.

OPERATION

Gender reassignment surgery in adolescents is less common than hormone treatment, but many centers are reluctant to give exact numbers.

The guidelines state that such surgery should generally be reserved for people aged 18 and over. The World Professional Association for Transgender Health says breast removal surgery is acceptable for people under 18 who have been taking testosterone for at least a year. The Endocrine Society says there is not enough evidence to recommend a specific age limit for this operation.

RESULTS

Studies have shown that some children and teens resort to self-harm to try to change their anatomy. And research has shown that transgender youth and adults are prone to stress, depression and suicidal behaviors when forced to live according to the gender they were assigned at birth.

Opponents of medical treatment of transgender youth say there is no strong evidence of purported benefits and cite widely discredited research claiming that most untreated children outgrow their transgender identity in adolescence or later. One study often cited by naysayers included many children who had been misidentified as having gender dysphoria and lacked outcome data for many others.

Doctors say accurately diagnosed children whose transgender identity persists through puberty usually don’t outgrow it. And the guidelines state that treatment should not begin before the onset of puberty.

Many studies show that treatment can improve children’s well-being, including reducing depression and suicidal behavior. The most robust type of study – a trial in which some distressed children receive treatment and others do not – cannot be done ethically. Longer-term studies on the results of the treatments are ongoing.

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Follow AP Medical Editor Lindsey Tanner on @LindseyTanner.

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The Associated Press Health and Science Department is supported by the Howard Hughes Medical Institute Department of Science Education. The AP is solely responsible for all content.

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