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    Management of adolescents with gender dysphoria



    Long-term considerations

    While gender-affirming hormone therapy provides many adolescents relief from GD, many others consider surgery essential to fully transitioning to their desired gender. The Endocrine Society recommends that surgery be deferred until age 16 for breast reduction and 18 for other surgical procedures, when adolescents have had sufficient social transition following cross-sex hormone therapy.

    Available surgical interventions include breast (“top”) surgery, genital (“bottom”) surgery, gonadectomy, facial or other plastic surgery, and hysterectomy with or without bilateral salpingo-oophorectomy. The Endocrine Society guidelines recommend hysterectomy to eliminate the risk of reproductive tract diseases as this population may not seek proper screening (Table 3).

    The gynecologist is important in this stage of transition not only because of surgical expertise but also because of the need for extensive counseling regarding the risks of a hypogonadal state and of hormone replacement. Due to increased risk of VTE in people receiving estrogen, this therapy is often discontinued the month prior to any major surgical procedure.3 There is anecdotal evidence that testosterone therapy may be associated with increased surgical bleeding. Therefore, treatment is often stopped prior to surgery. As adolescents transition into adulthood, they should undergo regular medical screening based on their current anatomy and age.

    Despite growing awareness of transgender issues in the medical community, marginalization of transgender individuals remains widespread.9 Furthermore, transgender youth comprise a disproportionate portion of the homeless population, limiting their access to medical and psychiatric care.10 Healthcare providers need to create a welcoming clinical environment for transgender patients. Changes to intake forms to include sexual minorities and using terms such as “relationship status” instead of “marital status” will help patients feel comfortable about their gender identity and expression.11

    It is important to discuss sexual orientation apart from gender identity and assess for pregnancy as well as sexually transmitted infections. Female-to-male patients who maintain their cervix should undergo cervical cancer screening. No data exist regarding vaginal cancer screening male-to-female individuals who have opted for genital surgery and creation of neovaginas; however annual visual inspection is a reasonable

    Jason Jarin, MD
    Dr Jarin is Fellow, Pediatric and Adolescent Gynecology, Washington Hospital Center, Washington, DC


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