Transgender Youths: Gynecologic Care

In the last 10 to 20 years, society has become more understanding and accepting of the 3% to 6% of individuals who fall under the umbrella of LGBTQ (lesbian, gay, bisexual, transgender, or questioning). The acronym refers to anyone who is non-heterosexual or non-cisgender (their experience of their phenotypic genders don’t match their psychological genders). Non-cisgender patients are now called transgender patients.

Adolescent transgender patients face many challenges, as do the medical professionals who care for them. What is the best way to manage transgender youths? This is a complex question with answers that rely on a case-by-case, ethical approach.

An article in Current Opinion in Obstetrics & Gynecology’s August 2014 issue offers some guidance to clinicians, ranging from the pediatricians who first encounter gender dysphoria in children, to the mental health professionals and gynecologists who help with transition.

Hormone therapy, also called cross-sex steroid therapy, is a cornerstone of the care provided. Unfortunately, its use increases risk for metabolic disorders and necessitates careful surveillance by healthcare professionals. The authors recommend 2 references for readers: the World Professional Association for Transgender Health recently updated its guidelines for healthcare professionals, and the Endocrine Society’s guidelines are available online.

The article goes on to cover controversies about time of surgery, should patients choose that route. As society accepts gender dysphoria as a real concern, surgeons are performing genital reassignment surgery earlier, with youths as young as 15 or 16 years old having successfully completed the process. Concerns about early reassignment are serious; the process requires emotional and physical maturity and is irreversible. For this reason, guidelines recommend waiting until the patient reaches the legal age of majority.

Healthcare clinicians need to be vigilant for mental health problems in this population. Depression and anxiety are understandably common, and 4 of 10 transgender youths attempt suicide. Transgender teens are also more likely to engage in high-risk behaviors than their peers.

The article stresses that transition is a lengthy process with ample opportunity for surgeons to help individuals. Often, transgender people begin exploring their medical needs with a gynecologist, but, ultimately, they need an entire support team.

Rejection, peer victimization, sexual harassment, and family problems are common. Transgender individuals are also at very high risk of dropping out of school. These patients need a model of care similar to the medical home.