Transgender Health Care Best Practices

Transgender Health Care Best Practices for Adolescents

In late 2017, The Journal of Clinical Endocrinology & Metabolism published updated guidelines for the medical care of transgender adolescent youth. A summary of those best practices are are listed on this page. You can download the complete 35-page article.

Evaluation

1. Trained mental health professionals who regularly attend relevant professional meeting and have knowledge regarding the criteria for puberty blocking and gender-affirming hormone treatments
2. Social transition of prepubertal kids with gender dysphoria and gender incongruence should be made with the help of a trained mental health professional
3. Recommends against puberty blocking and gender-affirming hormone treatment in pre-pubertal kids
4. Discuss fertility preservation options before beginning puberty suppression or hormone therapy

Treatment of Adolescents

1. Treatment to suppress pubertal development should happen first in adolescents who meet diagnostic criteria for gender dysphoria
2. Pubertal hormone suppression should begin with the first sign of physical changes of puberty
3. GnRH analogues should be used to suppress pubertal hormones
4. Sex hormone treatment should begin around age 16, using a gradually increasing dosage
5. Sex hormone treatment can begin before the age of 16, under the supervision of a multidisciplinary team of medical and mental health professionals
6. Doctor visits to monitor pubertal development every 3-6 months and lab work should be ordered every 6-12 months

Adverse Outcome Prevention and Long-Term Care

1. Clinical and laboratory monitoring should occur every 3 months during the first year of hormone therapy and then once or twice yearly after that
2. Transgender females using estrogen should monitor prolactin levels
3. Cardiovascular risk factors for all transgender people should be monitored with fasting lipid profiles, diabetes screening, and/or other tools
4. Bone mineral density measurements should be taken when osteoporosis risk factors exist
5. Breast screening guidelines for non-transgender females should be followed by transgender females with no known increased breast cancer risk
6. Prostatic cancer and disease risk for transgender females treated with estrogen should continue with individualized screening
7. Total hysterectomy and oophorectomy should be determined based on medical necessity and the individual”s gender-affirming treatment plan

Surgery for Sex Reassignment and Gender Confirmation

1. Surgery decisions should be made jointly with the patient, their mental health provider, and their doctor
2. Genital gender-affirming surgery should occur after at least 1 year of consistent and compliant hormone treatment, unless hormones are medically contraindicated
3. A transgender patient”s medical doctors should collaborate to clear the patient for gender-affirming surgery
4. Gender-affirming surgery should be considered after the person
   (1) has had a satisfactory social role change;
   (2) is satisfied with hormonal effects; and
   (3) desires definitive surgical changes
5. Gender-affirming surgeries such as gonadectomies and hysterectomies, should wait until the patient is of the age of majority, general 18
6. Breast reduction surgery for transgender males does not have a specific age requirement