Sorbara et al,1  in their report “Mental Health and Timing of Gender-Affirming Care” in this issue of Pediatrics, focus on the interesting matter of age of clinical presentation for gender-affirming medical interventions and its association with mental health in transgender youth. Because experiencing puberty is often stressful for gender-nonconforming youth, puberty suppression as a reversible medical intervention was introduced in clinical care in the early 2000s by Dutch clinicians Cohen-Kettenis et al.2  The aim of puberty suppression was to prevent the psychological suffering stemming from undesired physical changes when puberty starts and allowing the adolescent time to make plans regarding further transition or not. Following this rationale, younger age at the time of starting medical-affirming treatment (puberty suppression or hormones) would be expected to correlate with fewer psychological difficulties related to physical changes than older individuals. Sorbara et al1  confirmed this in their study. Adolescents presenting at younger age (<15 years) reported lower rates of self-reported diagnosed depression, self-harm, suicide thoughts or attempts, and use of psychoactive medication.

One could claim from these findings that gender-affirming medical interventions including puberty suppression should be offered at an early age (age <15 in the Sorbara study). Some caution is warranted, however, as the authors acknowledge in their report. One reason is that, despite the increased availability of gender-affirming medical interventions for younger ages in recent years, there has not been a proportional decline in older presenting youth with gender incongruence (GI), which is the discrepancy between one’s birth-assigned sex and experienced gender identity.3  It is even the case that most transgender people still present as older adolescents, as in the study by Sorbara et al1 , or as adults.4  Interestingly, this older adolescent group did not only have more mental health difficulties but also a later age of onset of GI. As seen by using medical records, the older presenting youth “simply experienced gender history events at older ages” before attending the clinic.1 

According to the original Dutch protocol, one of the criteria to start puberty suppression was “a presence of gender dysphoria from early childhood on.”2  Prospective follow-up studies evaluating these Dutch transgender adolescents showed improved psychological functioning.5  However, authors of case histories and a parent-report study warrant that gender identity development is diverse, and a new developmental pathway is proposed involving youth with postpuberty adolescent-onset transgender histories.68  These youth did not yet participate in the early evaluation studies.5,9  This raises the question whether the positive outcomes of early medical interventions also apply to adolescents who more recently present in overwhelming large numbers for transgender care, including those that come at an older age, possibly without a childhood history of GI. It also asks for caution because some case histories illustrate the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition.9,10 

A study at the Amsterdam transgender clinic, one of the oldest in the world, whose researchers aimed to gain insight in the possible changes of certain key characteristics of earlier compared with recent applicants, revealed no changes in intensity of gender dysphoria, psychological functioning, and age over time between 2000 and 2016.11  The only yet-unexplained observed change was a shift in sex ratio in favor of assigned female individuals. However, researchers of this time-trend study did not focus on differences between younger and older referred youth nor on the age of onset of gender nonconformity. In future, more-detailed studies like the one by Sorbara et al1  and the time-trend study by Arnoldussen et al,11  researchers should investigate whether older transgender adolescents might include individuals who experience later onset of GI, possibly postpuberty, and with more mental health challenges.

So far, researchers of the limited follow-up studies after puberty suppression show that the rate of adolescents that stop the reversible blockers is low (1.4%, 1.9%, and 3.5%).4,12,13  However, systematic studies on the rate of adolescents who discontinue their transitions after they have started affirming hormones or surgeries with lasting effects are lacking at present. Given these uncertainties, providing early medical treatment to transgender adolescents remains a challenging area to work in. Prospective longer-term follow-up studies of clinical samples like the study of Sorbara et al1  are needed to inform clinicians so that an individualized approach can be offered that differentiates who will benefit from medical gender affirmation and for whom (additional) mental health support might be more appropriate.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/2019-3600.

     
  • GI

    gender incongruence

1
Sorbara
JC
,
Chiniara
LN
,
Thompson
S
,
Palmert
MR
.
Mental health and timing of gender-affirming care
.
Pediatrics
.
2020
;
146
(
4
):
e20193600
2
Cohen-Kettenis
PT
,
Delemarre-van de Waal
HA
,
Gooren
LJ
.
The treatment of adolescent transsexuals: changing insights
.
J Sex Med
.
2008
;
5
(
8
):
1892
1897
3
World Health Organization
. ICD-11 for mortality and morbidity statistics (ICD-11 MMS) 2018 version.
2019
. Available at: https://icd.who.int/browse11/l-m/en. Accessed July 10, 2020
4
Wiepjes
CM
,
Nota
NM
,
de Blok
CJM
, et al
.
The Amsterdam cohort of gender dysphoria study (1972-2015): trends in prevalence, treatment, and regrets
.
J Sex Med
.
2018
;
15
(
4
):
582
590
5
de Vries
AL
,
McGuire
JK
,
Steensma
TD
,
Wagenaar
EC
,
Doreleijers
TA
,
Cohen-Kettenis
PT
.
Young adult psychological outcome after puberty suppression and gender reassignment
.
Pediatrics
.
2014
;
134
(
4
):
696
704
6
Kaltiala-Heino
R
,
Bergman
H
,
Työläjärvi
M
,
Frisén
L
.
Gender dysphoria in adolescence: current perspectives
.
Adolesc Health Med Ther
.
2018
;
9
:
31
41
7
Littman
L
.
Correction: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria
.
PLoS One
.
2019
;
14
(
3
):
e0214157
8
Zucker
KJ
.
Adolescents with gender dysphoria: reflections on some contemporary clinical and research issues
.
Arch Sex Behav
.
2019
;
48
(
7
):
1983
1992
9
Sevlever
M
,
Meyer-Bahlburg
HFL
.
Late-onset transgender identity development of adolescents in psychotherapy for mood and anxiety problems: approach to assessment and treatment
.
Arch Sex Behav
.
2019
;
48
(
7
):
1993
2001
10
Turban
JL
,
Carswell
J
,
Keuroghlian
AS
.
Understanding pediatric patients who discontinue gender-affirming hormonal interventions
.
JAMA Pediatr
.
2018
;
172
(
10
):
903
904
11
Arnoldussen
M
,
Steensma
TD
,
Popma
A
,
van der Miesen
AIR
,
Twisk
JWR
,
de Vries
ALC
.
Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals?
Eur Child Adolesc Psychiatry
.
2020
;
29
(
6
):
803
811
12
Brik
T
,
Vrouenraets
LJJJ
,
de Vries
MC
,
Hannema
SE
.
Trajectories of adolescents treated with gonadotropin-releasing hormone analogues for gender dysphoria [published online ahead of print March 9, 2020]
.
Arch Sex Behav
.
doi:10.1007/s10508-020-01660-8
13
Kuper
LE
,
Stewart
S
,
Preston
S
,
Lau
M
,
Lopez
X
.
Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy
.
Pediatrics
.
2020
;
145
(
4
):
e20193006

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.