Previous clinical recommendations on caring for transgender individuals have advised that hormone treatment begin no earlier than age 16 years, but a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even earlier.

“Sixteen is the typical age cutoff in many areas of the world for some decision-making capacity from a legal perspective, but when you think about hormones and puberty, 16 is pretty late,” Joshua D. Safer, MD , one of the task force members who authored the guideline, said in an interview. “If we’re going to use biology for guidance, then hormone interventions for transgender kids should begin occurring earlier, when puberty really happens, like around age 12, 13, or 14. However, we’re in a situation where we lack a test. We can’t diagnose anybody as transgender with excellent confidence, outside of talking to those kids. When we start talking about hormone therapies, we talk about some things that will be irreversible. That’s a fraught place to go, but we recognize that people are going to treat kids under 16 in many instances.”

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, which was published online in the Journal of Clinical Endocrinology and Metabolism, set no specific minimum age for hormone treatment (2017 Sept 13. doi: 10.1210/jc.2017-01658). This represents one of the substantial changes from the Endocrine Society’s 2009 published guideline on the topic, Dr. Safer said. Although there is a “much better understanding” of gender identity and care for transgender individuals since the first guideline appeared, “there remains a paucity of data. It remains a concern how little research has been supported up until now. We’re stuck with those gaps,” he said.

Over several years, Dr. Safer and nine other task force members, chaired by Wylie Hembree, MD, of the College of Physicians and Surgeons at Columbia University, New York, worked to establish a framework for the appropriate treatment of transgender individuals. The efforts of the task force were framed around a durable biological underpinning to gender identity. “That’s state of the art right now,” said Dr. Safer, who is the medical director of the Center for Transgender Medicine and Surgery at Boston University Medical Center. “People think there’s debate about whether there’s a substantial biological component. I think that the data are pretty strong, so I don’t think there’s a lot of debate about that in the scientific world. The debate is more about what that biology might be. That’s all over the map.”

That notion of a biological basis for gender identity contributed to a second major change from the Endocrine Society’s 2009 guideline, which recommended that the diagnosis of gender identity disorder be made by a mental health professional. The current guideline states that for the care of peripubertal youths and older adolescents, “we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents.” Meanwhile, for adult gender-dysphoric/gender-incongruent persons, “the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient.” Dr. Safer described this new approach as “a major change in terms of trying to gain access to care by liberalizing the variety of those in the medical community who can be associated with the diagnosis, at least on the adult side.”

A number of associations cosponsored the guideline, including the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Paediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and World Professional Association for Transgender Health. Other key recommendations from the guideline include:

Concurrent with the release of the new guideline, the Endocrine Society issued a position statement that calls on federal and private insurers to cover medical interventions for transgender individuals as prescribed by a physician. “I live in Massachusetts, where our insurance commissioner deemed insurance coverage obligatory for transgender individuals as of 2015,” said Dr. Safer, who is also director of the endocrinology fellowship training program at Boston University. “I’ve spoken to the medical directors of our large insurers, like Blue Cross/Blue Shield. What’s notable is that there has been no push back [on coverage for transgender individuals] from the insurance companies. These services are not expensive: the primary care, the mental health care, and the hormones. Many of the patients are not opting for surgeries. The theme of their concern was to get their [health insurance] policies right as quickly as possible so that they could stop wasting time talking about it, and they could focus their energy on other, more expensive health care concerns.”

In the guideline, Dr. Safer and the other task force members called for more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols in the future. “Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); (2) the effects of treatment in adults on sex hormone levels; (3) the requirement for and the effects of progestins and other agents used to suppress endogenous sex steroids during treatment; and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”

Dr. Safer reported having no financial disclosures.


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