2STIGD Youth

The following section outlines the information that pertains to gender-affirming care in relation to surgical options and interventions. This section is comprised of both visual and written material, and should be completed in the following order:

Watch Trans Care BC’s educational video on supporting gender creative children and their families.

1

Read and review the written guidelines and information outlined below.

2

It should be noted that there are a number of limitations and knowledge gaps with the current WPATH SoC which directly impact Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) youth. These are discussed in the section Children and Youth.

Informed Consent for Youth

Though there is a more in-depth discussion of the Informed Consent Model in Part 3, there are extra considerations to keep in mind when working with youth. The Medical Consent of Minors Act states that at the age of sixteen, youth are able to consent to medical treatment just as if they had reached the age of majority. According to the act, those under the age of sixteen are also able to consent to treatment if, in the opinion of the legally qualified PCP, they are capable of understanding the consequences and nature of the medical treatment, and if the procedure is in the best interests of the youth, their continued health and well-being. Similarly, the mature minor doctrine states that those able to understand the consequences and nature of a proposed treatment are able to consent to treatment regardless of age, which has been used in court to justify a minor’s right to consent. It should be noted that, while in the past the written opinion of a second legally qualified medical practitioner was required, this was amended in 2000 and is no longer a requirement.

Ideally, a supportive family member or guardian would be available to give consent on behalf of the patient. Unfortunately this is not always the case, and PCPs need to proceed with extra care with the awareness and understanding that in some cases, the patient may not have any adults in their life who support and respect their gender. In cases where the PCP will need to discern the patient’s capacity to consent, the teach-back technique, or asking the youth to rephrase what they have been told, can be useful, as well as inviting them to ask questions.

Privacy and confidentiality should also be carefully considered when working with youth, as in some cases they may not want their caregivers to be aware of their treatment. “In most situations, a capable young person has the right to determine who will be given access to their personal health information, including parents.” In these cases, it is essential to clearly communicate with the youth about how you plan to navigate this.

Medical Care

Gender-affirming medical care is necessary for some 2STIGD people, including youth. Options for medical care differ depending on the age and stage of development. Youth in the early stages of puberty may benefit from a period of puberty suppression followed by initiation of hormone therapy at a later age, whereas those who present in the later stages of puberty may proceed directly to GAHT.

A readiness assessment needs to be done prior to initiating medical care and should include all elements described in Part 4: GAHT (Gender-Affirming Hormone Therapy), as well as any necessary additional assessments (i.e., mental health) depending on the age and developmental stage of the youth and their social situation. In addition, PCPs must be prepared to work with families, educators, and others involved in the youth’s life to ensure the youth has adequate social support. As with adults, a readiness assessment can be completed by a range of professionals, including pediatricians and endocrinologists. Some clinical situations may warrant involvement of a specialist, either for consultation or for ongoing care. Things to consider are age and capacity of the youth, level of family support, youth’s ability/capacity to include caregivers in treatment decisions, presence of unstable or complex physical or mental health conditions, availability of specialists, ability to pay for a private specialist (e.g. psychologist), and the potential harms of delaying treatment. As always, specialist consultation should be obtained whenever a clinical situation feels beyond your training, experience, or comfort level at the present time. The following sections provide an overview about medical options that are available for children and youth.

Prepubescent Children

While children are not able to access medical transition care before puberty, many children and families find it helpful to have access to this information so they can understand their options and plan for the future. Knowing that there are medical options available as a child approaches adolescence can help prevent or relieve anxiety about pubertal changes.

PCPs working with 2STIGD children should strive to understand the various aspects of a child's identity and experience: racial, ethnic, immigrant/refugee status, religious, geographic, and socio-economic, for example, and to be respectful and sensitive to cultural context in clinical interactions. Many factors may be relevant to culture and gender, including religious beliefs, gender-related expectations, and the degree to which gender diversity is accepted by a child’s social supports.

Each child, family member, and family dynamic is unique, and can potentially encompass multiple cultures and belief patterns. PCPs should avoid stereotyping based on preconceived ideas which may be incorrect or biased (e.g., that a family who belongs to a religious organization that rejects gender diversity will be rejecting their child). Instead, it is essential to approach each family openly and understand each family member and family pattern as distinct.

As of 2017, all children and youth have the right to be free from discrimination because of sex, gender, sexual orientation, gender identity and gender expression. This right is founded in Article 2 of the UN Convention on the Rights of the Child, as well as in the Canadian Charter of Rights and Freedoms, and provincial and territorial human rights legislation. This legislation includes the protection of children and youth from harmful home environments under the Family Services Act. Although the legal age of consent to medical services in NB is 16, it is important that PCPs remain patient-centered when working with children. In the event that a caregiver refuses to support a child (including access to information, care, and community supports) and/or is actively withholding necessary mental and medical care to support a child's emotional and physical wellbeing, a PCP may be required to make a report to their local Child Protection Unit.

Talking to Caregivers

Studies have shown that while there are high rates of depression/suicidal ideation in trans youth, this directly corellates with whether they feel accepted and supported. In one study in particular, “family support was shown to be the strongest predictor of depression, anxiety and resilience.” Many trans youth rely on friends and peers, however family support has the greatest impact. This can be increasingly relevant for Two-Spirit Indigiqueer, and Indigenous trans and gender-diverse youth as their families and communities are commonly very closely knit.

In cases where caregivers are struggling to accept their child coming out, seeking medical transition, or socially transitioning, it’s important that the emotional burden of caregiver distress is not placed onto the youth. As a PCP, you can direct caregivers to resources (mental health services, support groups) that they can access to manage their reactions independently.

Puberty Suppression

Puberty blockers are medications that suppress the sex hormones that are produced by the body. These medications may be started soon after puberty begins. They put puberty on pause and can prevent changes such as voice lowering, body hair growth, breast growth and monthly bleeding. Effects will vary, depending on how far puberty has progressed before starting the blockers.

Youth in the early stages of puberty may benefit from a period of puberty suppression using leuprorelin (Lupron®) which is a GnRH analog. Leuprorelin safely blocks unwanted and distressing pubertal changes while allowing time for the youth to mature and for the youth and family to carefully consider decisions about further medical intervention.

Puberty blockers are often prescribed by an endocrinologist due to changing needs during adolescence. However, PCPs who are knowledgeable about gender-affirming care can work with an endocrinologist to provide this care and deliver routine monitoring.

If a youth is under age 18, the criteria for getting a prescription for a puberty blocker according to WPATH are:

A long-lasting and intense pattern of gender non-conformity or gender dysphoria.
Gender dysphoria emerging or worsening with the onset of puberty.
Any coexisting psychological, medical, or social problems are stable enough to start treatment.
The adolescent having given informed consent. If 16 years or older, the consent of a guardian is preferred but not required under the NB Medical Consent of Minors Act, though informed consent can be obtained from patients under the age of 16. See Informed Consent for Youth.

Effects of Puberty Blockers

For patients assigned male at birth, puberty blockers will stop or limit:

growth of facial and body hair
deepening of the voice
broadening of the shoulders
growth of the Adam’s apple
growth of the gonads and erectile tissue

For patients assigned female at birth, puberty blockers will stop or limit:

breast tissue development
broadening of the hips
monthly bleeding

In both cases, puberty blockers will temporarily stop or limit:

growth in height
development of sex drive
impulsive, rebellious, irritable or risk-taking behaviour (variable)
accumulation of calcium in the bones
fertility

There are no known irreversible effects of puberty blockers, so if a patient were to stop taking them their body would continue through puberty, picking up where it left off. These medications have been safely used for decades. However, there are risks associated with a health care provider withholding puberty blockers. Health care providers refusing to provide puberty blockers to youth can cause additional distress, and may lead to anxiety and depression. Withholding puberty blockers and hormone therapy is not a neutral option and can result in an increased risk of mental health issues, including suicidal ideation. Additionally, the financial costs associated with surgical transition later in life can be mitigated when patients do not experience the pubertal changes associated with their gender assigned at birth.

There are three main reasons that youth use puberty blockers:

The onset of puberty and the idea or reality of developing secondary sex characteristics that do not fit with their gender identity can be very distressing. Puberty blockers can help alleviate this distress.
If a child is still exploring their gender, puberty blockers allow additional time to explore without worrying about unwanted permanent physical changes.
Preventing unwanted physical changes can eliminate the need for some surgeries and procedures later on, such as male chest contouring and electrolysis.

GAHT

Some youth who take puberty blockers early in adolescence go on to start hormone therapy. Youth who have not taken puberty blockers may also take hormones. GAHT allows people to develop secondary sex characteristics that are in line with their gender identity, such as breast growth, softer skin, facial hair, or deeper voice. While not all 2STIGD youth will need or want GAHT, it is important that youth who do require this care have access to it.

Like puberty blockers, GAHT can be effective in alleviating a person's distress about their body and how they are perceived by others. Youth and their families or caregivers may work with an endocrinologist for GAHT and be monitored in partnership with their PCP. Youth, especially those who are older, may be able to access this care through a PCP depending on their case. PCPs can provide care planning, prescribing and monitoring of hormones if they have training in this area. Like adults, the same readiness assessment is required for youth. For more information, see Part 4: GAHT (Gender-Affirming Hormone Therapy) and/or the Endocrinology Guidelines for GAHT.

Surgery

In NB, gender-affirming surgery is insured under the Medicare Insurance Plan only when an individual is above the age of 18. For individuals under 18 who have the financial means, access to private gender-affirming surgery may be available and appropriate for youth ages 16 and above. More specifically, upper body surgeries may be appropriate; however, gonadectomy and genital surgeries are usually only done for youth 18 and older. Assessment by a PCP and the surgeon of choice is required (e.g., surgery readiness assessment).

DSM-5 (Adolescents): Gender Dysphoria

A marked incongruence between an individual’s experienced/expressed gender and their assigned gender that has been present for at least 6 months and is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
PLUS 2 of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
- A strong desire to be rid of one’s primary and/or secondary sex characteristics (or a desire to prevent the development of anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender
- A strong desire to be treated as the other gender
- A strong conviction that one has the typical feelings and reactions of the other gender

DSM-5 (Children): Gender Dysphoria

A marked incongruence between an individual’s experienced/expressed gender and their assigned gender that has been present for at least 6 months and is associated with clinically significant distress or impairment in functioning
A strong desire to be of the other gender or an insistence that one is the other gender
PLUS 5 of the following:
- A strong preference for wearing clothes typical of the opposite gender
- A strong preference for cross-gender roles in make-believe play or fantasy play
- A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
- A strong preference for playmates of the other gender
- A strong rejection of toys, games, and activities typical of one’s assigned gender
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender

Your Role as a PCP

What can you do?

Assess persistence and consistency in gender identity
Identify possible confounders: personality disorders, body dysmorphia, history of abuse, external pressures, etc.
Assess the severity of gender dysphoria
Prioritize referrals: early puberty (Tanner stage 2 is the optimal time to start pubertal suppression) or severe dysphoria
Offer menstrual suppression prior to endocrine appointment where applicable.
If patient is a candidate for GnRH agonists, order screening labs/BMD prior to pediatric endocrinology appointment
Arrange care with a WPATH trained mental health care provider
Assist in follow up care including monitoring screening labs/BMD and overall health and wellness.

Referral – Information to Include

Age
Pubertal stage
Severity of dysphoria (mental health, suicidal ideation/attempts)
Support from parents
Name of mental health care provider or other professionals
Your impression (support, hesitancy/doubts, areas to explore)
Baseline labs / investigations (if applicable)

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