Transgender children and adolescents

Management of transgender children and adolescents differ from those of transgender adults because children and adolescents are in the process of growth and maturity. They go through physical, mental, and social changes with age. Physicians and counselors must consider all factors, including age, developmental process, and other potential mental disorders, to provide appropriate guidance and treatment options to each individual patient.

Definition of children and adolescents

• Children refer to “individuals aged younger than 18”
• Adolescents refer to “individuals aged 10 – 21”
• Early adolescents refer to “individuals aged 10 – 14”
• Middle adolescents refer to “individuals aged 15 – 17”
• Late adolescents refer to “individuals aged 18 – 21”

Sexual Development

Infancy and childhood

At birth, an infant is assigned male or female status based on physical characteristics. Sexual development is static during the infancy period because the gonads are inactivated. However, aspects such as gender identity, experienced gender, and sexual attraction, begin to develop. Children aged 6-12 months can classify the gender of people around them.

Children aged 2-4 distinguish gender differences based on appearance. They self-identify as being male or female and often prefer to play with same-sex children rather than the opposite sex. They also begin to recognize different gender roles and perceive common “rules” applied to those in different gender roles. For example, men must have a short hair cut or wear pants while women must have long hair or wear a skirt.

Children aged 4-6 may play with their genitalia or act like they are masturbating.

School-age children have a better understanding of sex. They realize that there are no fixed rules. For example, a man may have long hair. At some point, children may be curious or begin to explore their sexuality. For instance, they may be interested in or want to play with toys of the opposite sex or try cross-dressing. However, if any children are particularly interested in toys or dresses of the opposite sex for an extended period, it may be a sign that they are dissatisfied with their gender. The parents may need to monitor this development.

Early adolescence

At this age, adolescents experience the most significant physical and reproductive changes. They become more interested in sex, both in terms of physical appearance and reproductive function. They often compare themselves with friends. Adolescents begin to develop attitudes toward sex. They also express interest in the opposite sex but in general interactions, such as starting a conversation on the phone, sending emails, texting, or chatting online.

Middle adolescence

At this age, the reproductive system will be as fully developed as in adulthood. With more sexual drive, the adolescents may start superficial dating or having a romantic relationship. However, relationships are mostly driven by mere attractiveness and sexual experimentation rather than intimacy. Most sexual behaviors involve exploring what works best for them. The middle adolescents try to understand their sexual orientation and find the essential meaning of love and relationship. The individuals with non-conforming gender identity tend to recognize whether they are male, female, or non-binary.

Late adolescence

In late adolescence, young adults start to develop a sense of self-identity and have a stable gender identity. They have opposite sex companions, talk about sex overtly with the opposite sex, and have increasing involvements in love and commitments.

Challenges of transgender children and adolescents

Transgender children and adolescents usually feel distressed by gender dysphoria, making them more vulnerable to mental disorders. This situation mainly happens to children and adolescents unable to express their identity publicly.

Because the sexual development of transgender children and adolescents is still in process, it is impossible to predict if they will become transgender adults or have an interchangeable identity, also known as "gender fluidity." This mostly happens in early adolescence (age 10-13). Therefore, appropriate counseling, especially on gender identity and social expressionism during the transition period, can reduce individuals’ distress levels without medical interventions.

Interventions for transgender children and adolescents

Some transgender children and adolescents decide not to seek healthcare personnel services because they want to avoid a negative experience. As a result, all physicians, nurses, counselors, and staff caring for transgender children and adolescents should have the right knowledge and non- judgmental attitudes and behaviors. The healthcare providers should also pay attention to details, for example, in addressing their name or choosing transgender children and adolescents' pronouns. They should introduce themselves first and ask transgender children and adolescents how these youths prefer to be addressed. Moreover, all providers should use appropriate body language with transgender children and adolescents.

Interventions during childhood or prepubertal period

Because it is not recommended to prescribe drugs and hormones to children of this age group, the best intervention is helping transgender children and adolescents develop their gender identity. Intervention should also focus on preventing potential problems, with special attention to psychosocial adaptation. Social acceptance should be encouraged. Providers should be aware that these children may feel distressed when rejected by some society members. In severe cases, surrounding people, such as family, teachers, and friends, must be educated to ensure the right understanding of transgender children and adolescents and acceptance of their identity. Furthermore, the environment should be adjusted for transgender children and adolescents for example preferred title, uniform, and restrooms.

In supporting transgender children and adolescents, counselors should consider their development and age-related perception. Counselors should also ensure that the families have an objective and non-judgmental attitude so that these children can eventually explore and accept their gender identity.7 In cases with a concomitant severe mental disorder, a transgender child should be referred to a child psychiatrist for further supervision. At this age, the counselor may provide information about a treatment plan in the future.

Interventions during pubertal period

Early and fully reversible medical interventions

When transgender children begin to experience physical changes during puberty, physicians should consider starting gonadotropin-releasing hormone (GnRH) analogues to suppress sex hormone production and consequently delay the physical changes of puberty. If the treatment is later discontinued, their original natal hormonal production resumes which makes this a reversible intervention. Side effects of GnRH analogues can be local reactions: erythema, induration, wheal and sterile abscess formation. Bone density decreases during therapy, but final peak bone mass is in the normal range. There are no reported serious side effects. However, GnRH analogues subsidized by the Universal Health Insurance Scheme in Thailand do not cover gender dysphoria cases.

Studies have demonstrated that GnRH analogues treatment could decrease the distress level caused by gender dysphoria in transgender children and adolescents. It also prevents undesired physiological changes in transgender children and adolescents in puberty, such as deepening of voice and breast development. It allows time for individuals to explore their gender identity before deciding to receive the next treatment, including surgery. Alternatively, they can decide to stop the treatment if later discovering that they are not transgender.

Partially or fully irreversible medical interventions

Gender-affirming hormone treatment in adolescents aims to change the physical characteristics to match their gender identity. Before initiating the intervention in transgender adolescents, service providers must conduct a complete psychosocial assessment. The adolescent has given informed consent. (If the patient is under 18 years old, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Indications for GnRH analogues treatment in transgender children and adolescents

1. Clear diagnosis of gender non-conformity or gender dysphoria in transgender children or adolescents over a long period of time.
2. Transgender children or adolescents with initial development of gender dysphoria, or worsening of symptoms with physical changes during puberty.
3. Other physical, mental, and social disorders were assessed and treated until under control.
4. Have received a full explanation and understand the treatment’s pros and cons and steps of treatment before signing a consent. (If a transgender child or adolescent is under 18 years old, parental consent must also be obtained).

Most gender-affirming hormone treatments begin when transgender adolescents are 16 years old. Sometimes, however, transgender children or adolescents may self-medicate with gender-affirming hormones before puberty (or at the age of 10 to 11) at the recommendation of their peers or other external sources. The improper use of hormones can be harmful. However, the counselor should be careful about recommending that transgender children or adolescents stop taking the hormone immediately in these cases because it may make them lose self-confidence and decide to discontinue treatment.

Providers should start by forming a functional working relationship with transgender children or adolescents so that they are willing to disclose prior usage of gender-affirming drugs and hormones in detail. Providers can then gradually begin the process of gender-affirming hormone treatment as follows:

1. Assess the risks and contraindications to prescribing gender-affirming drugs and hormones.
2. Instruct patients on the correct usage of gender-affirming drugs and hormones.
3. Prescribe gender-affirming drugs and hormones.
4. Explain the side effects that may arise from the use of gender-affirming drugs and hormones.

Gender-affirming treatment guidelines for transgender children and adolescents

Recommended type and dosage of gender-affirming hormones

Side effects of gender-affirming hormone treatment

Gender affirmation surgery

Gender affirmation surgery in transgender adolescents should follow the following clinical practice guidelines:

1. Transgender adolescents who have reached 18 years old are allowed to undergo sex reassignment surgery in Thailand.
2. Transgender adolescents should live life as the desired gender for at least 12 months to gain confidence and real-life experience before sex reassignment surgery.
3. Transgender adolescents must be evaluated and cleared for surgery by at least two professional psychiatrists.

Refer: Transgender Children and Adolescents, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University