Challenges in Timing Puberty Suppression for -Nonconforming Adolescents Annelou L.C. de Vries, MD, PhD

Sorbara et al,1 in their report “Mental however, as the authors acknowledge in Health and Timing of Gender-Affirming their report. One reason is that, despite Care” in this issue of Pediatrics, focus the increased availability of gender- on the interesting matter of age of affirming medical interventions for clinical presentation for gender- younger ages in recent years, there has affirming medical interventions and its not been a proportional decline in older association with mental health in presenting youth with gender youth. Because incongruence (GI), which is the experiencing puberty is often stressful discrepancy between one’s birth- for gender-nonconforming youth, assigned and experienced gender puberty suppression as a reversible identity.3 It is even the case that most Department of Child and Adolescent , Amsterdam University Medical Centers, Location VUMC, Amsterdam, medical intervention was introduced in transgender people still present as Netherlands clinical care in the early 2000s by older adolescents, as in the study by Dutch clinicians Cohen-Kettenis et al.2 Sorbara et al1, or as adults.4 Opinions expressed in these commentaries are those of the author and not necessarily those of the The aim of puberty suppression was to Interestingly, this older adolescent American Academy of Pediatrics or its Committees. prevent the psychological suffering group did not only have more mental DOI: https://doi.org/10.1542/peds.2020-010611 stemming from undesired physical health difficulties but also a later age of changes when puberty starts and onset of GI. As seen by using medical Accepted for publication Jul 14, 2020 allowing the adolescent time to make records, the older presenting youth Address correspondence to Annelou L.C. de Vries, plans regarding further transition or “simply experienced gender history MD, PhD, Department of Child and Adolescent ” Psychiatry, Amsterdam University Medical Centers, not. Following this rationale, younger events at older ages before attending Location VUmc, Room 1y130, PO Box 7057, 1007 MB, 1 age at the time of starting medical- the clinic. Amsterdam, Netherlands. E-mail alc.devries@ affirming treatment (puberty amsterdamumc.nl suppression or hormones) would be According to the original Dutch PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, expected to correlate with fewer protocol, one of the criteria to start 1098-4275). psychological difficulties related to puberty suppression was “a presence of Copyright © 2020 by the American Academy of physical changes than older individuals. from early childhood Pediatrics 1 2 Sorbara et al confirmed this in their on.” Prospective follow-up studies FINANCIAL DISCLOSURE: The author has indicated study. Adolescents presenting at evaluating these Dutch transgender she has no financial relationships relevant to this younger age (,15 years) reported adolescents showed improved article to disclose. 5 lower rates of self-reported diagnosed psychological functioning. However, FUNDING: No external funding. depression, self-harm, thoughts authors of case histories and a parent- POTENTIAL CONFLICT OF INTEREST: The author has or attempts, and use of psychoactive report study warrant that gender indicated she has no potential conflicts of interest to medication. identity development is diverse, and disclose. a new developmental pathway is COMPANION PAPER: A companion to this article can One could claim from these findings proposed involving youth with be found online at www.pediatrics.org/cgi/doi/10. that gender-affirming medical postpuberty adolescent-onset 1542/2019-3600. interventions including puberty transgender histories.6–8 These youth suppression should be offered at an did not yet participate in the early To cite: de Vries ALC. Challenges in Timing Puberty early age (age ,15 in the Sorbara evaluation studies.5,9 This raises the Suppression for Gender-Nonconforming Adolescents. Pediatrics. 2020;146(4):e2020010611 study). Some caution is warranted, question whether the positive

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 146, number 4, October 2020:e2020010611 COMMENTARY outcomes of early medical who discontinue their transitions outcome after puberty suppression and interventions also apply to after they have started affirming gender reassignment. Pediatrics. 2014; adolescents who more recently hormones or surgeries with lasting 134(4):696–704 present in overwhelming large effects are lacking at present. Given 6. Kaltiala-Heino R, Bergman H, Työläjärvi numbers for transgender care, these uncertainties, providing early M, Frisén L. Gender dysphoria in including those that come at an older medical treatment to transgender : current perspectives. age, possibly without a childhood adolescents remains a challenging Adolesc Health Med Ther. 2018;9:31–41 history of GI. It also asks for caution area to work in. Prospective longer- 7. Littman L. Correction: parent reports of because some case histories illustrate term follow-up studies of clinical adolescents and young adults the complexities that may be samples like the study of Sorbara perceived to show signs of a rapid 1 associated with later-presenting et al are needed to inform clinicians onset of gender dysphoria. PLoS One. transgender adolescents and describe so that an individualized approach 2019;14(3):e0214157 that some eventually .9,10 can be offered that differentiates who 8. Zucker KJ. Adolescents with gender will benefit from medical gender A study at the Amsterdam dysphoria: reflections on some affirmation and for whom transgender clinic, one of the oldest in contemporary clinical and research the world, whose researchers aimed (additional) mental health support issues. Arch Sex Behav. 2019;48(7): to gain insight in the possible changes might be more appropriate. 1983–1992 of certain key characteristics of 9. Sevlever M, Meyer-Bahlburg HFL. Late- earlier compared with recent ABBREVIATION onset transgender identity development applicants, revealed no changes in of adolescents in psychotherapy for intensity of gender dysphoria, GI: gender incongruence mood and anxiety problems: approach psychological functioning, and age to assessment and treatment. Arch Sex over time between 2000 and 2016.11 Behav. 2019;48(7):1993–2001 The only yet-unexplained observed REFERENCES 10. Turban JL, Carswell J, Keuroghlian AS. change was a shift in sex ratio in favor Understanding pediatric patients who 1. Sorbara JC, Chiniara LN, Thompson S, of assigned female individuals. discontinue gender-affirming hormonal Palmert MR. Mental health and timing However, researchers of this time- interventions. JAMA Pediatr. 2018; of gender-affirming care. Pediatrics. trend study did not focus on 172(10):903–904 2020;146(4):e20193600 differences between younger and 11. Arnoldussen M, Steensma TD, Popma A, older referred youth nor on the age of 2. Cohen-Kettenis PT, Delemarre-van de van der Miesen AIR, Twisk JWR, de Vries onset of gender nonconformity. In Waal HA, Gooren LJ. The treatment of ALC. Re-evaluation of the Dutch future, more-detailed studies like the adolescent : changing 1 insights. J Sex Med. 2008;5(8): approach: are recently referred one by Sorbara et al and the time- transgender youth different compared 11 1892–1897 trend study by Arnoldussen et al, to earlier referrals? Eur Child Adolesc 3. World Health Organization. ICD-11 for researchers should investigate Psychiatry. 2020;29(6):803–811 whether older transgender mortality and morbidity statistics (ICD-11 MMS) 2018 version. 2019. 12. Brik T, Vrouenraets LJJJ, de Vries MC, adolescents might include individuals Available at: https://icd.who.int/ Hannema SE. Trajectories of who experience later onset of GI, browse11/l-m/en. Accessed July 10, adolescents treated with gonadotropin- possibly postpuberty, and with more 2020 releasing hormone analogues for mental health challenges. 4. Wiepjes CM, Nota NM, de Blok CJM, gender dysphoria [published online So far, researchers of the limited et al. The Amsterdam cohort of gender ahead of print March 9, 2020]. Arch Sex follow-up studies after puberty dysphoria study (1972-2015): trends in Behav. doi:10.1007/s10508-020-01660-8 suppression show that the rate of prevalence, treatment, and regrets. 13. Kuper LE, Stewart S, Preston S, Lau M, J Sex Med – adolescents that stop the reversible . 2018;15(4):582 590 Lopez X. Body dissatisfaction and blockers is low (1.4%, 1.9%, and 5. de Vries AL, McGuire JK, Steensma TD, mental health outcomes of youth on 3.5%).4,12,13 However, systematic Wagenaar EC, Doreleijers TA, Cohen- gender-affirming hormone therapy. studies on the rate of adolescents Kettenis PT. Young adult psychological Pediatrics. 2020;145(4):e20193006

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Downloaded from www.aappublications.org/news by guest on September 30, 2021 Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents Annelou L.C. de Vries Pediatrics originally published online September 21, 2020;

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