Mental health needs of transgender teens

Treatment of transgender teenagers may often focus on gender reassignment and hormonal therapy, but a new report offers a glimpse at a host of other issues that pediatricians can help these young persons manage.

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Treating adolescents who are navigating gender identity issues can be a challenge. Parents may have 1 idea of what their child needs, but the patient might not be in agreement, leaving the pediatrician in the middle. Some guidance exists on navigating transgender therapies, but Johanna Olson, MD, lead author of a new study on transgender physiologic and psychosocial characteristics, hopes her new report will help healthcare providers gain a better understanding of their transgender patients.

Olson says parents often ask her to conduct chromosomal or hormonal testing to “explain” their child’s transgender experience. Olson, medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, says she hopes the revelation in the report that transgender adolescents have hormone levels consistent with their birth gender will help change these patterns.

“I hope that this report of normal hormone levels among transgender youth will dissuade parents, caregivers, and healthcare providers from believing that transgender experience comes from hormone imbalances, or that gender identity can be changed by administering additional hormones of a young person's endogenous puberty,” Olson says. “Follow-up manuscripts will describe the impact of medical intervention on physiologic and psychosocial outcomes in transgender adolescents.”

Besides conflicting ideas of what care transgender adolescents require, securing appropriate and timely treatment is a real problem. Olson says despite increased acceptance by the media and the public, transgender teenagers still suffer from a host of issues: from obesity to cover undesirable features, to depression, to high-risk behaviors. These issues are covered in the report-the first to study a large cohort of transgender adolescents and young adults seeking care for body dysphoria-which analyzed baseline characteristics of 101 individuals aged 12 to 24 years. A little more than half of the study participants were assigned a male gender at birth, and the report notes that baseline psychologic values were within normal ranges for assigned gender at birth.

NEXT: Gender dysphoria

Transgender includes individuals whose gender self-identification or expression does not match with established norms, particularly when the state of one’s internal gender identify does not match one’s assigned gender at birth. Gender dysphoria is defined as impairment of function, discomfort, or anxiety related to the disharmony between one’s gender at birth and the gender one feels.

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Transgender individuals can be socially and mentally stigmatized, and Olson says the result is an underserved group that is at risk for negative health outcomes.

According to the report, there are higher numbers of transgender adolescents seeking treatment related to gender dysphoria than ever before. This can present a challenge to the medical community, Olson says.

“Few providers feel educated and comfortable enough to treat transgender people, and ever fewer feel comfortable treating transgender youth,” Olson says. “Experiencing the wrong puberty for transgender youth leaves them vulnerable and often [can] trigger symptoms of depression, anxiety, maladaptive coping, and suicidality.”

Related to these symptoms, transgender young persons are more likely to face societal discrimination and are at greater risk for physical abuse that leads to drug abuse, economic marginalization, incarceration, sexually transmitted diseases, and homelessness.

The study included 51.5% of individuals who were assigned female gender at birth but identify as male (transmasculine), and 48.5% were assigned male gender at birth but identify as female (transfeminine). Transfeminine participants in the study were significantly older than transmasculine participants, according to the report. In addition, transfeminine participants were most often Caucasian, Latina, or other races, whereas transmasculine participants were mainly Caucasian. Fifty-three percent of participants still lived at home with their parents; 19% lived in their own home or apartment; and 5% lived with another family member. Another 23% lived in a group home, homeless shelter, or foster home. Testosterone levels for transmasculine participants were between 7 ng/dL and 288 ng/dL, but 4 of the participants had preexisting conditions that may have contributed to the higher baseline testosterone. Estradiol and prolactin levels were within normal ranges for transfeminine participants, according to the report.

More than half of the transfeminine participants studied and 94% of the transmasculine participants studied were living in their asserted gender roles at the time of the study, and the average age that they began living in their asserted gender roles was 16.8 years, according to the report. Eighty-eight percent had come out as transgender to their families at the time of the report, and most did so at the age of 17 years, although most first recognized feelings of deviation from their birth gender around age 8 years.

NEXT: Impact of early intervention

“One of the things that I reflect upon in this study is the average 9 years between internal realization of a gender identity different from assigned sex at birth, and disclosure to parents,” Olson says. “During a time of crucial brain development, transgender youth are internalizing negative messages about their core selves, a ‘secret’ they feel unable to share with their parents. Holding this knowledge inside during neuronal pathway development is likely profound. More research needs to be done to explore the impact of this experience in adolescence.”

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Olson says more studies are planned, but early intervention can provide transgender adolescents with better tools to deal with the changes they are facing, even as the medical community works to identify the best methods to help this population.

“Transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages,” Olson writes in the report. “Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. Evaluation of these youth over time will help determine the impact of medical intervention and mental health therapy.”

The fact that transgender young persons struggle with depression, anxiety, and suicidality is already known, but the study sought to describe the physical and psychosocial characteristics of adolescents and young adults seeking gender reassignment.

Twenty-four percent of the study participants suffered from mild to moderate depression, and 11% scored severe to extreme depression on the Beck Depression Inventory. Fifty-one percent reported thinking about suicide, and 30% had made at least 1 attempt.

In terms of risk behaviors, 43% of the study participants used drugs, including marijuana or cocaine, and 45% were sexually active (55% transfeminine and 37% transmasculine). The study notes that 6 transfeminine and 3 transmasculine participants had admitted to engaging in survival sex, which involves trading sex for money, food, drugs, or housing.

NEXT: Demographics of study population

Although sexual orientation and gender identify are not one in the same, the study did touch on the subject. Sixty percent of transfeminine participants described themselves as heterosexual females; about 13% identified themselves as lesbians; another 13% were bisexual females; and another 15% described themselves as “unsure” or “other.” Fifty-five percent of transmasculine participants identified themselves as heterosexual male; 10% as bisexual males; 2% as gay males; 2% as asexual; and 31% as “unsure” or “other.”

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All the transgender participants in the study wanted to begin hormonal interventions to help align their physical traits with their internal identify, and 2 were already beginning the process of hormonal treatment.

Despite the new knowledge presented in the study, Olson writes that there is still much work to be done.

“Transgender youth remain a very vulnerable population at high risk for many psychosocial challenges. As the medical care for these young people becomes better understood and more widely practiced, collecting longitudinal data from this cohort will assist providers in making difficult treatment decisions,” Olson writes. “Although there are guidelines and recommendations for the treatment of transgender-identified youth with puberty suppression in early adolescence followed by appropriate hormone therapy, there remain fundamental questions about when to start puberty suppression with gonadotropin-releasing hormone analogues, when to add cross-sex hormones, and how young is too young for gender confirmation surgery.”