An affirming approach to caring for transgender and gender-diverse youth

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Introduction

Paediatricians and other primary care providers (PCPs) are optimally positioned to support children and youth through the developmental processes that contribute to identity formation. Gender identity, a critical facet of a young person’s sense of self, first emerges in early childhood and evolves over the child and adolescent life course^[1][2]. Recent studies suggest that an increasing number of youth identify with a gender other than the sex assigned to them at birth, and demand and need for gender-related care within the paediatric health care system is growing^[3]-[10]. Paediatricians and PCPs may be the first professionals from whom transgender or gender-diverse (TGD) youth and their families seek support^[11]. However, providers often lack knowledge, training, and comfort in how to care for this population^[12][13]. This position statement reviews opportunities to provide affirming, supportive, inclusive, and non-judgmental care to youth of all gender identities across the health care system.

Terminology

Being familiar with common and appropriate terms to use when caring for TGD youth can help cultivate an affirming and supportive clinical environment^[14] (Table 1).

Table 1. Key terms relevant to gender-affirming care

Term	Definition
Assigned sex at birth, AMAB, AFAB	Referring to a person’s initial designation as male (“assigned male at birth” – AMAB) or female (“assigned female at birth” – AFAB) at birth, this label is based on the child’s genitalia and other visible physical sex characteristics
Cisgender	Individuals whose gender identity aligns with their sex assigned at birth
Gender-affirming care	Care provided to an individual to support their gender identity; this care may be medical, surgical, social, and/or psychological
Gender-affirming hormone therapy (GAHT)	Hormones prescribed to induce the development of secondary sex characteristics associated with an individual’s experienced gender: testosterone for those who seek masculine features, and 17β-estradiol for those seeking feminine features
Gender-affirming surgeries	Also called ‘transition-related surgeries’ or ‘gender-confirming surgeries’, this term refers to a range of surgical options that individuals may pursue as a component of transitioning
Gender-diverse	A broad term used to describe people with gender expressions or identities that are different from their assigned sex at birth. The term acknowledges and includes the vast diversity of existing gender identities. It replaces terms such as gender-nonconforming, gender-incongruent, and gender-variant, all of which have pathologizing or exclusionary connotations[14]. Not all transgender individuals identify with this term
Gender dysphoria	Refers to the distress that can arise from the incongruence between an individual’s experienced gender and their sex assigned at birth. Gender dysphoria is a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
Gender expression	The way a person portrays gender to others through external means, such as clothing, appearance, or mannerisms; this may or may not reflect gender identity
Gender identity	Also called ‘experienced’ or ‘affirmed’ gender, this is an individual’s internal, psychological sense of their own gender
Gender incongruence	Refers to a person’s marked and persistent experience of an incompatibility between their gender identity and the gender expected of them based on their sex assigned at birth. Gender incongruence is a diagnostic term used in the International Classification of Diseases Eleventh Revision (ICD-11). Use of this term should be limited to diagnostic contexts
Gonadotropin-releasing hormone agonist (GnRHa)	A long-acting pharmacological analogue of naturally produced gonadotropin-releasing hormone that is prescribed to inhibit production of pituitary gonadotropins (LH and FSH), thereby inhibiting gonadal production of sex steroids (i.e., testosterone or estrogen)
Medical transition	The process of undergoing medical treatment to align one’s physical experiences with one’s gender identity (e.g., by using hormone blockers or gender-affirming hormones)
Non-binary	A gender identity that is neither entirely male nor entirely female
Social transition	The process of expressing one’s gender identity outwardly to others through such actions as changing name, pronouns, and/or gender expression (e.g., clothing, hair style)
Transgender	An umbrella term used to describe all individuals with a gender identity that differs from their sex assigned at birth and physical sex characteristics. Not all gender-diverse individuals identify with this term
Transgender female, transfeminine, trans girl, trans female, formerly ‘MTF’	These terms describe an individual assigned male at birth but who identifies along the feminine spectrum
Transgender male, transmasculine, trans boy, trans male, formerly ‘FTM’	These terms describe an individual assigned female at birth but who identifies along the masculine spectrum
Two-Spirit	Referring to a person who identifies as having both a masculine and a feminine spirit, this term is used by some Indigenous communities and can encompass cultural, spiritual, sexual and/or gender identity

Note that terminology is sure to evolve with time.

*This table is also available as a downloadable resource.

The development of gender identity

Gender cognition emerges early in life. By 2 years of age, children are often able to identify differences between sexes, and by age 3, most can label their gender with ease^[1]. Over the course of the preschool years (ages 3 to 5) children develop an appreciation for gender stability — the notion that gender is stable over the life course^[15]. However, preschoolers do not typically recognize gender as an identity, but rather (and primarily) attribute it to external features and appearances^[16]. They are highly attuned to gender roles and behaviours, often aligning themselves closely with those of the same gender and expressing preferences for toys or activities that are stereotypically associated with their gender^[17]. At this age and stage, displaying gender-atypical behaviour does not necessarily reflect a gender identity that differs from assigned sex^[18]. Parents of young children should be encouraged to provide their child with a safe environment for gender exploration that does not make assumptions about future gender identity^[19].

By age 6 to 7 years, children begin to appreciate gender as an identity independent of external features. They may start to reduce outward or stereotypical expressions of gender, though they often continue to show affinity for same-gender peers and gender-typed toys and clothing through middle childhood^[1][16]. As they move through late childhood and transition into adolescence, a more sophisticated appreciation for gender identity emerges, with pubertal onset being a particularly salient event that may trigger more intensive reflection on the alignment of assigned and experienced gender^[20].

Most research on gender identity development has been conducted with cisgender children, using a White, Eurocentric lens. The developmental trajectory of children who do not identify with their sex assigned at birth is an active focus of scientific study, and characterizations of gender identities across cultures and ethnicities are only beginning to be recognized in the dominant literature. Recent research has suggested that some children may recognize a degree of ‘mismatch’ between their gender identity and their assigned sex as early as age 2 to 3 years^[2][16]. Similar to their cisgender peers, school-aged TGD children can have a strong sense of gender identity and a preference for peers of the gender with which they identify, along with the objects and activities they endorse or pursue^[1][17][21]. For others, awareness of a difference between assigned and experienced gender may not emerge until puberty or beyond^[2][22]-[24]. While current conceptualizations of gender are often categorical (i.e., binary: male versus female and fixed over time), emerging theoretical and empirical studies that employ multidimensional and dynamic constructs of gender may afford more nuanced insights into this domain, throughout the life course^[2][25][26].

A snapshot of transgender and gender-diverse youth

A growing number of youth articulate a gender identity that differs from the sex they were assigned at birth. Population-based studies from a number of high-income countries have estimated the proportion of the adolescent population who identify as transgender ranges at between 1% and 4%^[27]-[32]. A recent study of school-attending youth that asked about gender identity without using the term “transgender” found that 9.2% of respondents reported a difference between sex assigned at birth and experienced gender^[33].

TGD youth are at elevated risk for adverse health outcomes, including depression, anxiety, eating disorders, self-harm, and suicide^[34]-[45]. This elevated risk is thought, in part, to be attributable to ‘minority stress’, defined as the “distinct, chronic stressors minorities experience related to their stigmatized identities, including victimization, prejudice, and discrimination”^[46]-[48]. Consistent with this theory, Canadian TGD youth report high levels of exposure to harassment and violence^[49][50]. Risk may be mitigated by affirming experiences and environments, such as supportive parents, early social transition for those who express this desire, and inclusive and non-judgmental interactions with the health care system^[51]-[59].

Gender dysphoria

The term ‘gender dysphoria’ is often used descriptively, to characterize the significant distress that can arise when an individual’s experienced gender does not align with their sex assigned at birth. Clinically, the DSM-5-TR presents criteria for the diagnosis of gender dysphoria in children (Table 2), and in adolescents and adults (Table 3)^[60]. The inclusion of gender dysphoria in the DSM-5-TR is a topic of ongoing debate. Some argue that including the term promotes a binary view of gender and pathologizes gender diversity in a manner that perpetuates stigma. Others assert that its inclusion helps facilitate access to relevant services^[60][61]. The recently published World Professional Association for Transgender Health Standards of Care 8 (WPATH SOC-8) advocates that where a diagnosis is required to support access to care, the International Classification of Diseases Eleventh Revision (ICD-11) diagnosis of ‘gender incongruence’ should be used preferentially, when jurisdictionally feasible. This diagnosis does not require that there be distress associated with gender diversity, and is therefore considered less pathologizing^[62][63]. At present, however, the ICD-11 is not widely used in Canada. The utility of diagnosing either gender dysphoria or gender incongruence in young children is particularly contentious, because prepubertal children experiencing gender diversity may not continue to have this experience into adolescence, and medical interventions are not recommended for prepubertal children^{[2][20][64][65]}.

When an adolescent voices concerns of gender dysphoria, care should be taken to facilitate timely access to appropriate psychosocial supports and diagnostic assessment. In many jurisdictions, options for gender-affirming medical treatment require a formal diagnosis of gender dysphoria. Younger age and earlier pubertal stage at time of presentation for medically affirming care have been associated with lower rates of mental health conditions^[45][66]. Individuals diagnosed with gender dysphoria should be reassured that this diagnosis does not indicate “pathological” gender identity, but rather, characterizes the distress that arises from their sex assigned at birth not aligning with their identified gender^[2][61]. Formal efforts to change a young person’s gender identity, sometimes referred to as “conversion” or “reparative” therapy, are harmful and unethical and should not be undertaken^[58][61][62].

Table 2. Diagnostic criteria for gender dysphoria in children

Diagnostic Criteria

Gender Dysphoria in Children

A.  A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is other gender (or some alternative gender different from one’s assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Reference 60

Table 3. Diagnostic criteria for gender dysphoria in adolescents and adults

Diagnostic Criteria

Gender Dysphoria in Adolescents and Adults

A.  A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced and/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and /or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Reference 60

Strategies for providing a gender-affirming health care experience

Inclusive and affirming approaches to engaging youth in health care promote safety for all adolescents, and can be particularly impactful for youth with multiple structurally marginalized identities (e.g., Black or Indigenous adolescents)^[67]. Attention must be paid to both the environmental and interpersonal aspects of health care encounters, with particular focus on a welcoming clinical space, the use of affirming language, and adolescent-oriented care (Table 4)^{[35][59][68]-[82]}.

Table 4. Strategies for providing a gender-affirming health care experience

Objective	Strategies
Craft an affirming space	Display a clinic mission statement that explicitly articulates a commitment to inclusive care Have waiting room posters depicting youth with diverse gender expression[69][70] Ensure all intake forms and questionnaires allow for diverse responses to demographic questions[69][70] Designate bathrooms as gender-neutral[69][70] Have all medical staff routinely introduce themselves with their names and pronouns[71]
Employ inclusive language	Acknowledge diversity through language used in standard intake forms[69][72] Provide adolescents with the opportunity to articulate the name and pronouns that best resonate with their experiences and identities, and the option of documenting pronouns and preferred name in their health record[69][73]-[75] Consistently use an adolescent’s preferred name and appropriate pronouns[68][69] Train all staff interacting with youth in inclusive language[76] Phrase questions in neutral terms during history-taking to avoid assumptions (e.g., “Who makes up your family?” rather than “Do you live with your mother and father?”) Avoid labelling. Instead, focus on experiences (e.g., “Are you in a romantic relationship?” rather than “Do you have a boy/girlfriend?”)[35][68] Ask for guidance with language (e.g., “Is there a way you would like me to refer to your gender?” rather than “Do you identify as male, female, or non-binary?”) Use gender-neutral language during physical exam (e.g., “upper body” rather than “breasts”, or “genitals” rather than “penis/vagina”)[77][78] If you make a mistake with language, thank the youth for pointing out your error, apologize, and correct yourself
Provide adolescent-oriented care	Engage youth collaboratively in all aspects of health care Acknowledge specific intersections between an adolescent’s health and life experiences[79][80] Ensure confidentiality, but also review its limits with adolescents and involved parents or caregivers[35][69] Spend some allotted time alone with adolescents for every visit, without a parent or caregiver present[81] Support efforts to strengthen the parent–child relationship whenever possible[59][82]

A respectful, collaborative approach with adolescents positions the health care provider (HCP)’s medical expertise as complementing, rather than superseding, an adolescent’s expertise in their own life experience. Foster self-efficacy, promote autonomy, and encourage self-reflection by recognizing—and building on—the adolescent’s capacities^[83]. An affirming approach should never be directive, but rather, should support the adolescent in identifying and moving along the trajectory that best aligns with their individual goals^[30] through facilitated self-exploration and shared decision-making^[83]. Starting from a strengths-based stance, asking open-ended questions, and responding to statements with reflections and curiosity are motivational interviewing-informed strategies that can promote collaborative exploration of an individual’s motivation and goals. This approach also facilitates assessment of an adolescent’s capacity to make treatment decisions. While attending to the adolescent’s emerging autonomy, the value of having supportive family members or caregivers engaged in the life of the adolescent should also be emphasized. TGD youth with supportive parents have been shown to have markedly better mental health outcomes, including lower risk of suicide^[59][82]. Efforts to strengthen the parent–child relationship should be made whenever possible.

Recognize the psychosocial context

During the one-on-one portion of each visit, consider exploring an adolescent’s experiences using the HEEADSSS psychosocial interview tool^[84]. A question pertaining to gender identity should be included for all youth, and can be phrased simply: “How do you describe your gender identity?” For TGD youth, additional questions exploring how their gender identity may impact or be affected by their experiences across psychosocial domains should be integrated into the HEEADSSS assessment (Table 5). If a concern is identified, further assessment and resources may be needed to ensure a holistic, safe care trajectory.

Table 5. Sample HEEADSSS questions for transgender or gender-diverse youth

Domain	Question
Home	Are your parents or caregivers involved and supportive of your gender identity? Do those you live with use your appropriate pronouns? Do you feel safe expressing your gender identity at home?
Education and employment	Are you able to express your gender safely at school? Do you have access to a preferred washroom at school?
Eating	Do you ever restrict or increase what you eat to change your body’s appearance to better match your gender identity?
Activities	Do you feel comfortable expressing your gender during after-school activities? Do you have supportive peers and friends?
Drugs	If you use substances, is this ever related to feelings about gender?
Sexuality and gender	Are there particular genders you are attracted to? If you have a partner, does your partner know about and support your gender identity?
Suicide/depression	How do you feel about having a gender identity that differs from the sex you were assigned at birth?
Safety	Are there places where, or people with whom you choose not to share your gender identity? Is this because you have safety concerns?

Clinical components of gender-affirming care

Gender-affirming medical interventions may be an important component of comprehensive care for some TGD adolescents. Open dialogue with an adolescent that emphasizes the diversity of paths that TGD individuals can take is critical to ensuring an individualized approach. Some TGD adolescents may only ever desire social transition, while others may pursue social transition initially and later become interested in medical options, while still others may articulate a clear goal of medical transition from early in adolescence. After completing a comprehensive biopsychosocial assessment, the following options for gender-affirming medical interventions may be considered for adolescents with marked and sustained gender diversity^[62].

Hormone blockers

Also referred to as puberty blockers or hormone-suppressing agents, hormone blockers are medications that mitigate the effects of endogenously produced sex steroids. Hormone blockers commonly prescribed in Canada, and key considerations for their use are reviewed in Table 6. Hormone blockers can suppress sex steroid-mediated experiences, such as menses (for AFAB youth) or erections (for AMAB youth), and pause or slow sex steroid-related physical changes that continue into young adulthood. Gonadotropin-releasing hormone agonists (GnRHa) are hormone blockers that, if started before pubertal development is complete, will pause pubertal progression. Hormonal suppression is reversible, and endogenous sex-steroid production and/or effects will resume if hormone blockers are discontinued^{[62][64][85]-[89]}.

Initially, the clinical objective of prescribing a hormone blocker is to provide a young person with time to further explore their gender identity without pressure or distress related to ongoing development of secondary sex characteristics, or gendered experiences such as menses or erections^{[18][23][62][64][85][90]}. Should a young person continue to express gender dysphoria over time and eventually wish to pursue other gender-affirming treatments, GnRHa may also prevent the further development of irreversible secondary sex characteristics that can make medical and surgical transition more difficult^{[18][62][64][85][86]}. Additionally, their blocking action may also allow for the use of lower doses of gender-affirming hormones to achieve phenotypic transition goals later on^[64][78][91].

TGD adolescents who have sought and received hormonal suppression as a part of a multidisciplinary approach to care report improved mental health and psychosocial functioning^{[37][85][92]-[94]}. Access to these medications has been associated with lower odds of suicidal ideation over the life course^[95]. Treatment with a GnRHa during puberty is associated with a slowing of bone mineral density accrual, which at least partially reverses with the start of gender-affirming hormone therapy or the resumption of endogenous sex-steroid production^{[86][96]-[101]}. The utility of baseline and routine repeat DEXA scans for those on a GnRHa is an area of ongoing research and debate. Concerns voiced by opponents of gender-affirming medical care around the potentially permanent impacts on cognitive function of temporarily blocking sex-steroid exposure during adolescence have not been substantiated to date^[102].

Hormone blockers should not be prescribed before the onset of puberty (i.e., Tanner stage 2) for two reasons. First because concentrations of circulating sex steroids in prepubertal children are already low, but also because the onset of puberty is an important experience through which young people may develop clearer understanding of their gender identity^{[18][20][64][85][86][90]}. Initiating hormone blockers in early puberty may have both positive implications for gender-affirming surgical options (e.g., more surgical options for chest wall masculinization) and negative ones (e.g., less scrotal tissue for vaginoplasty) for those who desire such interventions in the future^[64][103]. Detailed guidance for the initiation of hormone blockers is available in guidelines from the Endocrine Society^[64] and WPATH SOC-8^[62].

Although hormone blockers do not permanently impact fertility, speaking with adolescents about the option of fertility preservation before starting a blocker is recommended for several reasons. Fertility preservation cannot always be performed while on a blocker and, once initiated, some youth may be hesitant to discontinue blocker use to facilitate these procedures^{[64][90][104]}. Because fertility preservation may not be conducted (outside of research contexts) for adolescents in early puberty, eliciting their views on fertility may be relevant for timing hormone blocker initiation in some individuals.

Table 6. Commonly used hormone blockers in gender-affirming medical care

Agent	Key considerations
For individuals assigned female at birth (AFAB)
Gonadotropin-releasing hormone agonist (GnRHa; leuprolide acetate for depot suspension)	Administered intramuscularly (IM), typically every 4 or 12 weeks Acts on the hypothalamic–pituitary–gonadal (HPG) axis to inhibit gonadal production of estrogen, and therefore the most effective blocker option Side-effects may include pain, redness, and irritation, or a sterile abscess at injection site (in approximately 5% of cases), hot flashes during the first few months post-initiation, mood fluctuations (i.e., irritability, low mood) around time of initiation, decreased libido, headaches, or visual changes (including a rare association with idiopathic intracranial hypertension) May experience a “surge” bleed after the first dose Can slow rate of linear growth if administered during the pubertal growth spurt If not taken on schedule, can cause resumption of puberty Expensive (for some, costs may be covered under provincial/territorial benefits programs, private insurance, or a manufacturer’s compassionate coverage program) If stopped, endogenous puberty/hormonal effects typically resume within 6 months Advise weight-bearing exercise and optimizing calcium and vitamin D intake to promote bone health. Consider obtaining a baseline DEXA to assess pre-initiation bone mineral density ECG is recommended for adolescents undergoing therapy with another medication known to prolong the QT interval or those with family history of QTc abnormalities Use as monotherapy for an extended (i.e., typically >2 years) period of time may introduce potential risks associated with prolonged lack of exposure to sex steroids
Combined oral contraceptive pill	Taken by mouth (PO) once daily When prescribed continuously, may reduce frequency of menstrual bleeds Does not stop further pubertal development Can treat dysmenorrhea and act as a contraceptive Requires daily adherence to be effective Side effects may include nausea, chest tissue tenderness, spotting, bloating Increased risk of thromboembolism.Adolescents must be assessed for contraindications Contains female hormones (estrogens and progestins), which may be source of distress to TGD youth
Depot medroxyprogesterone acetate (DMPA)	Administered IM, typically every 12 weeks Can reduce frequency of menstrual bleeds, but this effect is variable. Typically is more effective with longer use Does not stop further pubertal development Side effects may include pain, redness, or irritation at injection site, weight gain, decreased libido, mood fluctuations, breakthrough bleeding Use as monotherapy for an extended (i.e., typically >2 years) period may introduce potential bone health risks Advise weight-bearing exercise and optimizing calcium and vitamin D intake to promote bone health Contains female hormones (progestins only), which may be source of distress to TGD youth
Levonorgestrel-containing intrauterine device (LNG-IUD)	Inserted into the uterus by a trained HCP. Effective for up to 5 years Can reduce frequency of menstrual bleeds, but this effect is variable Does not stop further pubertal development Expense can be prohibitive Can treat dysmenorrhea and act as a contraceptive Side effects may include discomfort at time of insertion, breakthrough bleeding, acne Contains female hormones (progestins only) and may be considered invasive, which may be sources of distress to TGD youth
Progestin-only pill	Taken by mouth (PO) once daily Can reduce frequency of menstrual bleeds, but this effect is variable based on progestin type and dose. Typically is more effective with longer use Does not stop further pubertal development Some formulations can treat dysmenorrhea and act as a contraceptive Requires daily adherence to be effective, including strict adherence (i.e., use at the same time each day) for some formulations Side effects may include spotting, breast tenderness, acne, decreased mood Contains female hormones, which may be source of distress to TGD youth
For individuals assigned male at birth (AMAB)
Gonadotropin-releasing hormone agonist (GnRHa; leuprolide acetate for depot suspension)	Considerations similar to those outlined above for AFAB youth Acts on the hypothalamic–pituitary–gonadal (HPG) axis to inhibit gonadal production of testosterone, and therefore the most effective blocker option Youth may experience transient increase in frequency of erections after the first dose Unlikely to inhibit erections completely, but may reduce frequency and duration
Spironolactone	Pills taken PO 1 to 2 times daily Blocks action of testosterone, but mild ongoing exposure can occur, causing some individuals to retain some sexual function Requires daily adherence to be effective May slow but will not fully prevent pubertal progression Requires electrolyte monitoring Side-effects may include fatigue, mood fluctuations, decreased libido, headache, increased urination Can cause gynecomastia (an increase in the amount of breast tissue), which may be a desired effect for some individuals
Cyproterone acetate	Pill taken PO daily or every other day Acts both centrally and peripherally (progestogenic and anti-androgenic effects). Can be more effective than spironolactone Requires adherence to be effective May slow but will not fully prevent pubertal progression Side-effects may include mood fluctuations (more pronounced than for spironolactone), fatigue, decreased libido, bloating, acne Prolactin monitoring is required. Cyproterone acetate has been associated with increased risk for hyperprolactinemia, particularly when used alongside estrogen Has been associated with increased risk of meningioma. Can be associated with hepatotoxicity. Contraindicated for individuals with hepatic dysfunction

BMD Bone mineral density; DEXA Dual-energy X-ray absorptiometry; HCP Health care provider; TGD Transgender or gender-diverse

Gender-affirming hormones

For some adolescents with marked and sustained gender diversity, gender-affirming hormone therapy (GAHT) can be an important care component^[62][64]. GAHT is prescribed to promote the development of physical features that are better aligned with an individual’s experienced gender^{[62][64][98][105]}. For AFAB individuals wishing to appear more masculine, testosterone esters are prescribed, while for AMAB individuals who desire a more feminine physique, 17β-estradiol is used. Starting doses for hormone medications in adolescents are typically lower than those prescribed in adults, with doses being titrated up over time in a manner intended to simulate pubertal progression in sex-steroid exposure^[64][91].

GAHT is considered a partially reversible intervention because hormone administration over time results in both reversible and irreversible changes^[62][64]. Irreversible effects of testosterone include voice deepening, clitoral enlargement, body and facial hair growth, and, possibly, androgenetic alopecia. Changes to body composition (e.g., fat redistribution and increased muscle mass), increased libido, acne, mood fluctuations, and menstrual suppression are considered reversible effects of testosterone. Once the serum testosterone level is within the adult masculine range, exogenously administered testosterone will suppress endogenous production of estrogen and, therefore, menses. Reaching this level takes time, and individuals often continue GnRHa or other forms of menstrual suppression while testosterone doses are titrated.

Estradiol will, over time, induce irreversible breast tissue development. Reversible effects of estradiol include skin softening, changes in body composition (e.g., fat redistribution, decreased muscle mass), fewer spontaneous erections, and changes in the quality of body hair. The reversibility of estrogen’s effect on testicular volume remains unclear^[106]. Treatment with estrogen alone is not effective for suppressing endogenous testosterone production. Because testosterone interferes with estradiol treatment, individuals typically continue to use hormone blockers for the duration of GAHT unless gonadectomy (the surgical removal of the testes or the ovaries) is pursued^[64]. Otherwise, much higher doses of estrogen, with attendant health risks, are required.

Both testosterone and estradiol can permanently decrease fertility to an extent that is not yet fully known. It is essential for prescribers of GAHT to explore adolescents’ desires regarding future genetically related offspring and, when indicated, to refer for fertility preservation before initiating therapy^{[62][64][90][91]}. GAHT must never be used as a method of contraception. Engaging all adolescents in conversations about contraception and the types of sexual encounters in which contraception is needed to prevent unwanted pregnancies is a critical component of promoting safe sexual practices.

Prescription of GAHT should only be provided to adolescents with a confirmed diagnosis of gender dysphoria or gender incongruence who demonstrate the capacity to understand and appreciate both the benefits and risks of these medications, given their profound effects^[62][64]. Any co-existing psychological, medical, or psychosocial issues that interfere with treatment should be addressed to ensure the adolescent is stable enough to start GAHT^[62][64]. When GAHT is initiated appropriately for adolescents who desire this option, it has been associated with improved perceived well-being and mental health, decreased suicidality, and decreased body dissatisfaction^[107]-[109]. GAHT is considered safe for adolescents, but it can have associated short- and long-term health risks that are beyond the scope of this statement to review^{[62][64][91][105][110][111]}. HCPs who are considering prescribing gender-affirming hormones must familiarize themselves with these risk profiles and associated recommendations for monitoring, which are described in guidelines from the Endocrine Society^[64] and WPATH SOC-8^[62]. HCPs who feel they lack the knowledge or skills to prescribe GAHT should ensure timely referral of interested adolescents to colleagues who can offer such care.

Gender-affirming surgery

While gender-affirming surgeries are less commonly performed in the adolescent population, TGD youth may identify surgery as one of their transition goals. Being aware of the most common gender-affirming surgeries, and talking about them with adolescents who express interest, can position paediatric providers to support patient education and reflection on if (or how) such interventions might fit into their future lives^[112].

The most frequently sought out gender-affirming surgery among AFAB individuals is chest wall masculinization (bilateral mastectomy with male chest contouring), typically referred to as ‘top’ or ‘upper’ surgery^[113]. ‘Bottom’ or ‘lower’ surgeries are pursued by some TGD individuals. However, these procedures are restricted to individuals 18 years of age and older. They can include surgeries to create a phallus (clitoral release, metoidioplasty, phalloplasty) or hysterectomy with or without bilateral salpingo-oophorectomy for AFAB individuals, and vaginoplasty or orchiectomy in AMAB individuals^[62][64]. Processes and age cut-offs for funding gender-affirming surgeries vary by province/territory in Canada.

Recommendations

• Health care providers (HCPs) should adopt an affirming approach to care for all children and youth, including those who are transgender or gender-diverse (TGD).

• HCPs should develop the knowledge required to counsel TGD children and youth and their families on options for medically affirming care (Table 7). If HCPs feel they are not able to develop adequate knowledge to provide such counselling, they must refer TGD children and youth to relevant resources to support optimal care.

• Increased training on affirming care should be integrated into paediatric and paediatric subspecialty training programs across Canada.

• HCPs with the relevant knowledge and skills must be supported in initiating and maintaining pubertal TGD youth on hormone-blocking agents while awaiting specialized gender care.

• HCPs with the relevant knowledge and skills must be supported in initiating and maintaining pubertal TGD youth on gender-affirming hormone therapy.

• HCPs should advocate for timely access to specialized gender-related care.

• HCPs should advocate for all spaces where children and adolescents spend time to be safe for, and inclusive of, those with a TGD identity, including schools and extracurricular activities.

• Gender-affirming care must be upheld as standard of care for TGD youth

Table 7. Clinical steps to gender-affirming practice

1. Ensure a safe, welcoming space	Learn current, appropriate terminology If unsure of language, ask patients for guidance Train all staff to use affirming language for every office encounter Post images and provide resources that signal a diverse, inclusive culture of care in the waiting room Implement adolescent-oriented office procedures (e.g., designating some time for confidential care at all visits, flexible scheduling, walk-ins, follow-ups by phone or text)
2. Provide early, proactive family care	Encourage parents to create a home where gender identity is not assumed, stigmatized, or enforced Strengthen the parent-child relationship when and however possible Engage family, extended family, alternate caregivers, and community supports for parents and adolescents Promote trustful, collaborative therapeutic relationships, with a child’s or youth’s best interests as the guiding focus
3. Respond to adolescents’ needs	Be open to discuss options and pathways for TGD individuals, OR Ensure timely referral to colleagues who can offer this care Be sufficiently familiar with gender-affirming hormone therapy (GAHT) to either discuss benefits and risks of each intervention, and monitoring protocols, OR Ensure timely referral to colleagues who can offer this care Elicit an individual’s fertility goals and discuss fertility preservation to guide timing of hormone blocker initiation, AND Refer to experts before starting medical treatment, as appropriate Invite questions and conversations about contraceptive health and sexual encounters where contraception is needed Be able to discuss how gender-affirming surgeries (though less common for TGD adolescents) might (or might not) fit into future life, OR Refer to colleagues who can offer this information
4. Support adolescent mental well-being	Use the HEEADSSS psychosocial interview tool Reassure that ‘gender dysphoria’ reflects related distress and a pathway to supportive services, not “pathology” Use motivational interviewing to assess individual motivation, life goals, capacity to make treatment decisions
5. Optimize health outcomes	Address co-existing psychological, medical, or psychosocial issues, if present Be equipped to monitor and provide follow-up care for individuals who start hormone treatment Be aware of appropriate screening tests (e.g., monitor electrolytes in adolescents prescribed spironolactone to block hormones)

Acknowledgements

This position statement has been reviewed by the Community Paediatrics and Mental Health and Developmental Disabilities Committees of the Canadian Paediatric Society. It was also reviewed by representatives of the Canadian Pediatric Endocrine Group (CPEG).

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CANADIAN PAEDIATRIC SOCIETY ADOLESCENT HEALTH COMMITTEE (2021-2022)

Members: Holly Agostino MD; Marian Coret MD, MSc, BSc (Resident-member); Megan Harrison MD FRCPC; Ayaz Ramji MD (Board-representative); Alene Toulany MD, MSc, FRCPC; Ashley Vandermorris MD, MSc, FRCPC; Ellie Vyver MD, FRCPC (Chair)

Liaison(s): Amy Robinson MD, FRCPC (Adolescent Health Section)

Principal authors: Ashley Vandermorris MD, MSc, FRCPC; Daniel L. Metzger MD, MSc, FRCPC

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.