Addressing Legislation That Restricts Access to Care for Transgender Youth

Kremen, Jessica; Williams, Coleen; Barrera, Ellis P.; Harris, Rebecca M.; McGregor, Kerry; Millington, Kate; Guss, Carly E.; Pilcher, Sarah; Tishelman, Amy C.; Baskaran, Charumathi; Carswell, Jeremi; Roberts, Stephanie

doi:10.1542/peds.2021-049940

Cited by 19 publications

(7 citation statements)

References 24 publications

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“…Although the significance of the risks may be unclear, there is strong evidence regarding the benefits of GnRHa in transgender youth: it can be a life-changing and lifesaving treatment for a vulnerable population who is at high risk for anxiety, depression, and suicide. 4,5,7 The treatment decisions for transgender youth can be complex, with many factors that need to be considered. The novel findings provided by the study of Nos and colleagues 6…”

Section: + Related Articlementioning

confidence: 99%

“…The decision to initiate GnRHa therapy represents an independent therapeutic decision for a clinician, ideally working in concert with a multidisciplinary team of both medical and mental health clinicians. 5 Limitations of the study of Nos and colleagues 6 merit discussion. They included younger children compared with earlier studies, which is a strength of the study, but as younger age was associated with higher GnRHa discontinuation rates, this could explain the finding.…”

mentioning

confidence: 99%

“…3,4 Recently, the use of GnRHa has received attention because of legislated concerns regarding the medical and surgical treatment of transgender youth, including criminalizing the provision of this care in some states. 5 Without evidence, the assumption has been made that GnRHa treatment leads to increased ultimate use of gender-affirming therapy (GAT) in transgender youth and that prescription of a GnRHa inappropriately advances the decision to start GAT. The article by Nos et al 6 provides data to the contrary-that this therapy can be offered both for mental health and cosmetic benefits without the concern of increasing the subsequent use of GAT.An understanding of the medical management of a transgender child or adolescent is needed to appreciate the issues at hand.…”

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confidence: 99%

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Pubertal Blockade and Subsequent Gender-Affirming Therapy

Guss

Gordon

2022

JAMA Netw Open

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For youth who identify as transgender or are unsure and wish to explore possibilities before the development of permanent secondary sex characteristics, use of a gonadotropin-releasing hormone analogue (GnRHa) is a key medical option. Sometimes colloquially called "puberty blockers," they have been used safely for decades in children with precocious puberty 1 and endometriosis, 2 among other medical indications. Multiple professional societies now endorse pubertal blockade for youth with gender dysphoria. 3,4 Recently, the use of GnRHa has received attention because of legislated concerns regarding the medical and surgical treatment of transgender youth, including criminalizing the provision of this care in some states. 5 Without evidence, the assumption has been made that GnRHa treatment leads to increased ultimate use of gender-affirming therapy (GAT) in transgender youth and that prescription of a GnRHa inappropriately advances the decision to start GAT. The article by Nos et al 6 provides data to the contrary-that this therapy can be offered both for mental health and cosmetic benefits without the concern of increasing the subsequent use of GAT.An understanding of the medical management of a transgender child or adolescent is needed to appreciate the issues at hand. 3,4,7 A GnRHa is more potent than native GnRH and produces initial stimulation of pituitary gonadotrophs, with increased secretion of follicle-stimulating hormone, luteinizing hormone, and gonadal hormones, followed by downregulation of the pituitary-gonadal

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Section: + Related Articlementioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Pubertal Blockade and Subsequent Gender-Affirming Therapy

Guss

Gordon

2022

JAMA Netw Open

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“…This high rate has led some clinicians, judges, and legislators to express concerns that initiation of GnRHa treatment in young adolescents does not serve as a pause in pubertal development, but instead inappropriately advances the decision to start gender-affirming hormones to a younger age when the adolescent has not yet completed the cognitive development required to assent to this treatment. 8,[24][25][26][27] Guidelines for gender-affirming care suggest that most adolescents do not reach cognitive maturity until age 15 to 16 years, after most have completed puberty and can no longer obtain maximum benefit from GnRHa treatment. 8 In the United Kingdom, a court ruled that GnRHa treatment could not be administered to transgender patients younger than 16 years without a court order because they assert that this treatment inevitably leads to use of gender-affirming hormones.…”

Section: Introductionmentioning

confidence: 99%

Association of Gonadotropin-Releasing Hormone Analogue Use With Subsequent Use of Gender-Affirming Hormones Among Transgender Adolescents

et al. 2022

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ImportanceGonadotropin-releasing hormone analogue (GnRHa) use during puberty improves mental health among transgender and gender-diverse (TGD) adolescents. In previous studies, most (96.5%-98.1%) TGD adolescents who started GnRHa subsequently started gender-affirming hormones (GAH), raising concerns that GnRHa use promotes later use of GAH.ObjectiveTo determine whether GnRHa use among TGD adolescents is associated with increased subsequent GAH use.Design, Setting, and ParticipantsThis is a retrospective cohort study of administrative records collected between 2009 and 2018. The current analysis was completed in August 2022. Participants were enrolled in the US Military Healthcare System (MHS) with an initial TGD-related encounter occurring between ages 10 and 17 years.ExposuresGnRHa use.Main Outcomes and MeasuresInitiation of GAH.ResultsThe 434 patients were a mean (SD) of 15.4 (1.6) years old at the time of their first TGD-related encounter; 312 (71.9%) were assigned female at birth, and 300 (69.1%) had an enlisted insurance sponsor. GnRHa use was more common among patients who were assigned male at birth (28 patients [23.0%]) than those assigned female (42 patients [13.5%]), but GAH use was not. Socioeconomic status was not associated with GnRHa or GAH use. Compared with older patients (aged 14-17 years), those who were younger (aged 10-13 years) at the time of the initial TGD-related encounter had a higher rate of GnRHa use (32 patients [57.1%] vs 38 patients [10.1%]) and a longer median time to starting GAH. The median interval from the date of the initial encounter to starting GAH decreased over time, from 2.3 years (95% CI, 1.7-2.8 years) between October 2009 and December 2014 to 0.6 years (95% CI, 0.5-0.6 years) between September 2016 and April 2018. Patients who were prescribed GnRHa had a longer median time to starting GAH (1.8 years; 95% CI, 1.1-2.4 years) than patients who were not (1.0 years; 95% CI, 0.8-1.2 years) and were less likely to start GAH during the 6 years after their first TGD-related encounter (hazard ratio, 0.52; 95% CI, 0.37-0.71). Among 54 younger (aged 10-13 years) patients who were not eligible to start GAH at their first encounter, GnRHa use was associated with a longer median time to starting GAH, but age at the first TGD-related visit was not.Conclusions and RelevanceIn this cohort study of TGD adolescents, GnRHa use was not associated with increased subsequent GAH use. These findings suggest that clinicians can offer the benefits of GnRHa treatment without concern for increasing rates of future GAH use.

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“… 1. For example, in April 2021 the Arkansas state legislature banned gender-affirming treatment for transgender youth, and dozens of similar bills were introduced in state legislatures across the United States (American Civil Liberties Union, 2021; Kremen et al, 2021) …”

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confidence: 99%

Supporting Gender Self-Determination for People With Intellectual and Developmental Disabilities

Hughes

2022

Inclusive Practices

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People with intellectual and developmental disabilities (I/DD), including those with significant support needs, continue to advocate for access to self-determination so that they can have choice and control in their lives. Under the purview of self-determination, people with I/DD should be able to determine how they express their gender. However, supporters sometimes enforce their own beliefs about gender, thus restricting people with I/DD to traditional gendered expectations of men and women. Through self-advocate stories and a review of research that has examined the experiences of gender-diverse people with I/DD, this article highlights the importance of supporting access to gender self-determination. I provide examples of how family members and professionals can support gender self-determination for people with I/DD, including those with significant support needs.

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Addressing Legislation That Restricts Access to Care for Transgender Youth

Cited by 19 publications

References 24 publications

Pubertal Blockade and Subsequent Gender-Affirming Therapy

Pubertal Blockade and Subsequent Gender-Affirming Therapy

Association of Gonadotropin-Releasing Hormone Analogue Use With Subsequent Use of Gender-Affirming Hormones Among Transgender Adolescents

Supporting Gender Self-Determination for People With Intellectual and Developmental Disabilities

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