Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents

Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents

“…As noted above, the recommendations in this document draw on clinician consensus, standards of care, 8 treatment guidelines and position statements, [9][10][11][12][13][14][15] and limited data from non-randomised clinical and observational studies. [16][17][18][19][20][21][22][23][24][25][26][27] It is clear that further research is warranted across all domains of care for TGD children and adolescents, the findings of which are likely to influence future recommendations.…”

“…The Australian standards of care and treatment guidelines (the statement) are based primarily on clinician consensus, along with previously published standards of care, 8 treatment guidelines and position statements, [9][10][11][12][13][14][15] and data from a limited number of non-randomised clinical studies and observational studies. [16][17][18][19][20][21][22][23][24][25][26][27] In creating the Australian statement, we consulted all the known child and adolescent psychiatrists, paediatricians, paediatric endocrinologists and allied health specialists who work clinically in the area of transgender health across Australia. A list of contributors from the Royal Children's Hospital Gender Service team and contributing organisations and individuals from within the TGD community is provided in the Acknowledgements section of the full version, which is available at https:/ /www.rch.org.au/ adolescent-medicine/gender-service/.…”

“…The main concern with use of puberty suppression from early puberty is its impact on bone mineral density owing to the absence of the effect of oestrogen or testosterone on bone mineralisation. 23,27 Regular monitoring of bone mineral density during stage 1 treatment is recommended. 9…”

The primary health care of transgender adults

“…29,30 Post SRS, transmen and transwomen become hypogonadal if exogenous hormones are ceased, and treatment should continue for life. 33 The effects of gonadotrophin-releasing hormone (GnRH) agonists on BMD in transgender adolescents are unknown, 42,43 but experience from using these drugs in the treatment of precocious puberty suggests that the small decreases observed in BMD during treatment are promptly reversed on cessation. 44,45 How well this can be generalised to transgender populations and cross-hormone therapy is unknown, as these young people generally do not start cross-hormone therapy until 16 years of age: beyond the normal range of pubarche, and well into the period in which peak bone mass is accrued.…”

How Should Physicians Help Gender-Transitioning Adolescents Consider Potential Iatrogenic Harms of Hormone Therapy?

“…The current SOC guidelines do not set strict age criteria for the start of either intervention [10]. This is somewhat remarkable since the only scientific evidence of the psychological efficacy [20,31] and medical efficacy and safety [21][22][23][24]32] of the treatment is based on the "Dutch protocol" as it was introduced. At that time, the protocol set strict minimum age criteria for starting puberty suppression (12 years of age), cross-sex hormone treatment (16 years of age), and gender-affirming surgeries (18 years of age) [33].…”