medwireNews: The Endocrine Society has published an update to its 2009 guidelines for the treatment of people with gender dysphoria, including recommendations for the diagnosis and management of children and adolescents.

The previous guidelines referred to the treatment of “transsexual persons”; the term has now changed to people with “gender dysphoria” or “gender incongruence”.

The diagnostic recommendations remain similar to those in the 2009 guidelines, although the criteria for healthcare professionals evaluating patients have been expanded. Those evaluating children and adolescents should have specific training for this age group, as well as knowledge of treatment criteria, in addition to meeting the requirements for evaluating adults.

Wylie Hembree (Columbia University Medical Center, New York, USA) and fellow guideline authors still advise against blocking puberty or initiating hormone treatment in pre- or early-pubescent patients, given the high proportion of gender dysphoria cases that do not persist into adolescence.

The team does not wholly rule against a complete social role change for all pre-adolescent patients. However, they emphasise that a complete change can be hard to return from if gender dysphoria does not persist. Moreover, it may actually contribute to the persistence of gender dysphoria.

“This recommendation, however, does not imply that children should be discouraged from showing gender-variant behaviors or should be punished for exhibiting such behaviors”, they write in The Journal of Clinical Endocrinology & Metabolism.

They add that “[i]n individual cases, an early complete social transition may result in a more favorable outcome”, but stress that there is as yet no means to identify such cases, and that currently the persistence of gender dysphoria “can only be reliably assessed after the first signs of puberty.”

The guideline writers also emphasize the importance of the involvement of a mental health professional in any decisions regarding a change of social role. As in the previous edition, they recommend counselling patients about the preservation of their fertility during treatment.

Recommendations for treating adolescents are again mostly in line with the 2009 advice, including, where indicated, use of gonadotropin-releasing hormone analogues to suppress pubertal development, initiated after the first physical signs of puberty, and treatment with sex hormones beginning around the age of 16 years.

In a shift from the previous guidelines, Hembree and team recognise that “there may be compelling reasons” to start treatment earlier in some cases, despite the paucity of published evidence in support of this, and advise the involvement of a multidisciplinary team, including mental healthcare professionals, in such decisions.

Another new inclusion in this section is the advice to monitor pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during treatment.

Recommendations relating to sex reassignment surgery that were previously included under treatment of adolescents are now in a dedicated surgery section. These have not changed, however; the guidelines still advise waiting to establish satisfaction with the new social role and hormonal changes and a definite desire for irreversible changes, and for the individual to reach 18 years of age or their country’s legal age of adulthood.

The guidelines also cover treatment of adults and offer recommendations for long-term care, including preventing adverse outcomes. However, the authors acknowledge that more solid evidence of treatment safety and effectiveness is still needed, including “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)”.

By Eleanor McDermid

J Clin Endocrinol Metab 2017; Advance online publication

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