Intake

1. You will start by getting a referral, usually from your child’s pediatrician.
2. Next, you will receive an intake call from the Transgender Health Program to gather some information and answer your questions.
3. Most often, your first appointment at a Doernbecher Gender Clinic is scheduled one to three months after we receive your referral.

First appointment

What to expect: We usually do not prescribe medications during the first visit. We will:

• Get your child’s medical history and family history.
• Discuss your support network and access to mental health therapy.
• Possibly do a physical exam and blood test to assess the extent of puberty.
• Review treatment options, and their benefits and risks.
• Guide you through the consent process, which can be complex.
• Answer your questions and help you find any resources you need.

Other visits

We will monitor your child throughout treatment. Typically, we see patients every three to four months.

What is pubertal suppression?

Pubertal suppressants (GnRHa or GnRH) are modified natural hormones that stop your child’s body from making estrogen or testosterone. Your child also may receive hormone treatments such as:

• Progesterone to suppress menstruation
• Antiandrogens to block testosterone

How pubertal suppressants work

Puberty produces hormones in pulses that spur development, but suppressants deliver a steady amount. That essentially puts the puberty system to sleep. Children can stop taking them at any time. If they do so without starting hormone therapy, they will resume puberty based on the sex that was assigned at birth.

When they’re given: Pubertal suppressants are usually given in the early stages of puberty, after changes have begun. They aren’t effective until then. They often take several months to start working. Suppressants taken later in puberty don’t reverse changes but can stop new ones.

How they can be given:

• Injections into a muscle every three months.
• Small implants placed under the skin of the inner upper arm. These are usually replaced every one to two years if pubertal suppression continues.

Risks of pubertal suppression

Deciding on suppressants involves weighing physical risks against the mental health risks of gender dysphoria, which can include:

• Anxiety
• Depression
• Suicidal thoughts
• Substance abuse

Long-term effects: Suppressants have been used for decades to treat children who start puberty too early. They have proved safe and effective in cisgender children. Currently, there is limited information about the long-term effects in gender-diverse patients.

Risk to bones: Suppressants can’t be used indefinitely without hormone therapy because of health risks such as weak bone density. Bone-building exercises and taking calcium and vitamin D can help. We will monitor your child for potential problems.

Fertility: Suppressants should not affect your child’s ability to have children. Staying on them and then taking gender-affirming hormones may permanently reduce your child’s fertility, though. We will discuss risks and fertility-saving options with you.

Getting pubertal suppressing treatment

We assess each child individually. We’ll discuss all aspects of this treatment to help you make an informed decision.

We recommend starting with a mental health evaluation for your child, which we can help arrange. Then we generally follow WPATH guidelines for recommending treatment. Guidelines include:

• The child has shown a long-term, intense pattern of gender nonconformity or gender dysphoria, whether suppressed or expressed.
• Gender dysphoria emerged or worsened when puberty began.
• Psychological, medical or social problems that could disrupt treatment have been addressed. The child is stable enough to start treatment.
• The child has given informed consent. If the child is not old enough to give medical consent, the parents or guardians have consented and will support their child through treatment.

What is hormone therapy?

Estrogen and testosterone are hormones that develop some traits and reduce others. Hormone therapy mimics the body’s production of estrogen or testosterone. It causes some of the changes a child goes through in puberty.

Hormone therapy doses — how much and how often — are typically different for teens than for adults. They’re designed to help patients start the puberty that matches their gender identity.

How hormone therapy works

In teens, hormone therapy can make appearance, emotions, sexual feelings and other traits more closely match gender identity. Hormone therapy also affects people in different ways and at different rates. Genetics may play a role in how fast changes happen, how big breasts get or how thick facial hair is.

Estrogen: Estrogen can be given in a pill, skin patch or injection. Regular doses can cause breasts to develop, and fat to form under the skin and in hips and thighs.

Testosterone: Testosterone is usually injected into muscles or just under the skin. It typically causes an increase in muscle mass and strength, and prompts hair to grow on the face and body.

Risks of hormone therapy

Estrogen therapy: There are few serious health concerns, but patients may be tested for high blood pressure, higher cholesterol levels and other risks. Some changes, such as to fertility (the ability to have biological children) or chest development, may be permanent.

Testosterone therapy: Long-term risks are unclear. Some changes, such as to fertility or a deeper voice, may be permanent.

Patients may be monitored for:

• High red blood cell count
• Lower good cholesterol
• Higher bad cholesterol levels
• Liver problems

Before starting hormone therapy

• We will talk with you about options, what to expect and possible risks.
• We can refer you to fertility experts to discuss options.
• We don’t require patients to transition socially before starting hormone therapy.
• We prefer that patients get a mental health evaluation before starting hormones. We also recommend that patients and their families get mental health support throughout transition. Doernbecher offers psychological and psychiatric care.

When to start hormone therapy

Endocrine Society guidelines suggest that patients, families and care teams decide together when to start hormone therapy, based on the patient’s individual needs. Most teens have the maturity to make these decisions by age 16. Therapy may start earlier for reasons such as:

Physical development issues:

• Delaying puberty too long may carry risks such as harm to bone density. It can also cause adolescents to be taller or shorter than the norm for their gender identity.
• Many teens want to go through puberty with their peers.
• It may be safer for teens to appear physically mature as they get older.
• Suppressants may not be effective if an adolescent has gone through most stages of puberty.

Gender dysphoria: Appearing sexually immature in the mid- to late teens can worsen gender dysphoria. It can also put teens at higher risk of mental health problems and substance abuse.

A stable life: Teens may have lived comfortably in their gender identity for a year or more. They may be prepared for transition mentally, physically and emotionally.

Transition desires: Most teens with gender dysphoria will carry it into adulthood. They may want to begin their transition as soon as possible.