Gender diverse children and young people
Key points:
Listen to the child, let the child lead their journey as much as possible.
Support parents to learn how to best support their child. Family support leads to better outcomes
If a child is insistent, consistent and persistent about their gender identity being different to that assigned at birth or clear distress expressed related to gender then social affirmation is usually beneficial.
Most families don’t require medical support for social transition/affirmation.
If puberty blockers (GnrH agonists) are being considered, referring to specialist services around age 9 years, prior to puberty onset is recommended. Some children are not distressed by puberty and don’t need blockers.
Puberty blockers can be used from tanner stage 2-3.
It is important to reassure the child and family that puberty does not move quickly.
For those assigned female at birth, the commencement of menses means much of physical puberty has usually occurred and the benefits of using a blocker often don’t outweigh the risks, given there are good alternatives for menses cessation.
For those assigned male at birth, puberty blockers are useful in later tanner stages for blocking ongoing effects of endogenous testosterone and can be started prior to gender affirming hormones.
Gender affirming hormone therapy is usually started from age 16 years (or younger in some cases) in those on puberty blockers who wish to go onto hormone therapy.
General Information
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Be there for the family, acknowledge this can be a distressing time for family members worrying about their child or adolescent and what this means for their child’s future and safety .
Remind the family that the evidence is clear that children and teens do best with the love and support of their families.
Acknowledge the long history of gender diversity that has been recognised (and often celebrated pior to colonisation) in many cultures including for Māori and Pasifika.
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Kids and Gender is a toolbox with lots of information to support parents of younger children and adolescents. Click here to access.
Click here for a great NZ whānau support resource
Click here for a useful hub of information for Māori whānau.
Click here for an organisation supporting Pasifika Rainbow young people and includes resources about positive family journeys.
Connect family to peer supports such as the NZ parent and caregivers online support networks. This is a great way for parents to feel connected, learn practical information on how best to support their child navigate social affirmation both at home and then at school, learn about medical and know they are not alone on this journey.
The national group (which operates via facebook) will usually have information on local in person groups as some parents often prefer this. Or check out your local Health pathways information.
Families often need time to process their child’s journey, but for families who are continuing to struggle, individual counselling may be beneficial.
Other resources for parents
The Gender Identity workbook for kids. A guide to exploring who you are By Kelly Storck – this provides very useful information for any family supporting a younger child who is gender diverse, transgender or NB .
Click here for a helpful general guide for families.
Click here for Family support information
Outline.org.nz provide peer and counselling support to trans people and their families alongside other resources Resources include an easily printable resource for parents
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Gender can be affirmed in different ways e.g. using a different name, pronoun, clothing or hairstyle. Let the child lead this and take it at a pace that feels right for them. This can be in different spaces e.g. often initially at home, with different family members, friends, social settings and school.
Safety should always be considered when navigating social affirmation
School affirmation/transition supports:
Inside out have great resources for schools and have school coordinators in many regions. Families can contact them directly for information and specific support.https://www.insideout.org.nz/
This is a really helpful resource for a parent supporting their child to navigate a school transition - http://transcend.org.au/wp-content/uploads/2021/07/Transcend_A-Guide-for-Parents-Carers-1.pdf
If a child is insistent, consistent and persistent about their gender identity being different to that assigned at birth or clear distress expressed related to gender (i.e.people not understanding their gender to be different to sex assigned at birth) then social affirmation is usually beneficial.
If distress is not improved by social affirmation measures and is impacting on the child, further support may be needed e.g. counselling, child and adolescent mental health services, or access to secondary gender affirming care supports if available. Find out the supporting services in your region, often detailed on local Health Pathways.
Most families do not need medical support to navigate social affirmation but for some families connecting in with gender affirming health professional support can be beneficial.
Supporting peer connections
Rainbow Youth are a national organisation that facilitate peer support and connection groups through out the country for young people 13+ https://ry.org.nz/
Schools often have their own diversity groups that young people may want to join.
The parent network may be a source of peer connection for younger children
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Engagement is key
Discuss confidentiality
Use the desired name and pronoun where safe to do so, this may be different if family are present. Clear documentation around this is important.
Update the medical system with name and gender when safe to do so.
Ask what language they would like you to use for describing their gender.
Explore goals of gender affirming care
Encourage family engagement wherever possible
Use the HEeADSSS Assessment focusing on a strengths based approach to establish risks and resiliencies and include anxiety screening
Consider if the young person may be neurodiverse and how this might impact on your communication and engagement . This should not prevent access to gender affirming care .
Explore triggers for gender dysphoria as a way to see what might be helpful to manage distress – e.g. social affirmation, chest binding, menses cessation, padding, tucking, hair removal options, vocal therapy.
Discuss safe binding https://genderminorities.com/find-transgender-info-services/medical-surgical/binders-2/binding-info/
Consider options for accessing free binders via GMA https://genderminorities.com/find-transgender-info-services/medical-surgical/binders-2/national-free-binder-programme/
Rainbow Youth may have funding or access to free binders https://ry.org.nz/
Poorer mental health is more commonly seen in trans young people compared to their cis gender peers. Further mental Health support may be required at a primary or secondary level – refer as appropriate .
Puberty blockers
These are usually started as part of a multidisciplinary team process involving secondary care, and then continued in the primary care setting.
The timing of blocker initiation can impact future fertility and surgery options, which is why connecting with a health professional who can provide clear information to the family around this is recommended. In some areas, this may be a GP with a special interest in gender-affirming care or a GP liaising with secondary care.
It is important that access to secondary care does not delay timely access to puberty blockers for those children who will clearly benefit from them.
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GnrH agonists can be used from tanner 2-3 .
Puberty staging in early tanner stages is best done by examination, though blood tests can confirm if child is in early puberty if the young person is not wanting to be examined. Examination should only be done with full consent.
Self report of Tanner staging may be less accurate particularly in early pubertal stages .
Early am LH, FSH and oestradiol or testosterone can help assess if the child is in puberty – LH > 0.5 is often the first indicator of puberty onset.
It is important to reassure the child and family that puberty does not move quickly.
The timing of Gnrh agonist commencement (ie tanner staging at time of initiation) can impact on future fertility and surgery options, which is why it is important to assess where possible in younger adolescents. Clear discussion around this information is required prior to starting the puberty blocker.
Where fertility preservation is possible for those assigned male at birth (usually tanner stage 3-4+ ),sperm storage should be discussed and offered prior to blocker commencement.This is DHB funded.
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For those assigned male at birth Puberty blockers /GnRH agonists are useful in later tanner stages for blocking ongoing effects of endogenous testosterone and can be started prior to gender affirming hormones.
For those assigned female at birth, once menses has commenced much of physical puberty has usually occurred (certainly by 2 years post menses). At this stage the benefits of using a blocker usually don’t outweigh the risks, and given there are good alternatives for menses cessation management these are usually preferred.
Menses cessation can be supported in primary care.
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Leuprorelin or goserelin is usually given 10-12 weekly in a primary care setting.
It is important to give the injection on time to maintain good H-P-GN axis suppression
Things to check at each appointment:
Check the young person still keen to continue on the blocker
Are they having the desired effect? Ie Blocking further puberty changes
Ask about side effects - hot flushes are the most common side effect, are usually tolerable and commonly settle within 6 months .
Promote Bone Health - encourage weight bearing exercise , consider Vitamin D supplementation and review calcium intake. (Bone Density screening is not routinely done in NZ unless there are other risk factors eg Anorexia Nervosa)
If the adolescent wants to stop the GnRH agonist make sure they fully understand what will happen (ie puberty changes will continue) and liaise with secondary care or initial prescriber of puberty blocker if applicable.
Monitoring blood tests are usually guided by initial prescriber and are commonly done just before the 3rd blocker is due then 6-12 monthly.
Bloods to consider - FBC, Urea, electrolytes, creatinine, LFT’s, LH, oestradiol or testosterone levels- to review how well they are suppressed.
Lipids and HbA1C (consider annually or more frequently if risk factors are present).
AMAB - aim for testosterone to be in the cis female range.
AFAB - aim for oestradiol to be <50/undetectable (if aiming for full suppression i.e. tanner stage 2-4) otherwise review based on clinical effect if just aiming for menses cessation.
Low 1 hr LH level after blocker will help to confirm full H-P-GN suppression and is sometimes done if there is physical concern that the young person is not fully blocked, despite low sex hormone levels. This may be more important in earlier tanner stages.
Monitor Growth - height, weight and blood pressure.
If not well blocked on GnRH agonist , shorten interval to 8- 10 weekly or use a double dose of Lucrin or switching to goserelin may be recommended.
Goserelin is the only funded Gnrh agonist beyond adolescence. This is a subcutaneous implant and potentially a little more painful to insert.
Lucrin ( leuprorelin ) prescription – need to write “certified condition unable to tolerate goserelin” on the script to ensure it will be.
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Gender affirming Hormone Therapy
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Starting hormones for adolescents is an individualised process based on a person's gender journey, maturity to give informed consent , family or other adult supports, and safety considerations.
Most adolescents start hormones from age 16 years (or older if not already on puberty blockers).
Adolescence is a time of identity development. Encourage young people to fully explore gender as part of their identity, take their time in making decisions around hormones or surgery, and ensure a good understanding of risks and benefits prior to medical or surgery affirmation.
Discuss the importance of parent or caregiver involvement (unless this is not thought to be safe or necessary). This is particularly important to consider if still living in the family home .Taking a little extra time to allow families to catch up on this journey may lead to better long term family support.
World Professional Association for Transgender Health (WPATH) have provided a Standard of Care (SOC8) which gives recommendations around training for those working with gender diverse adolescents. This includes training and expertise in gender affirming care, youth development, adolescent mental health and neurodiversity. This may mean a mental health professional, paediatrician or adolescent health specialist experienced in gender affirming care will be involved to provide additional support prior to commencing hormones, however this requirement should not act as a barrier to accessing care.
There should be a pathway in most regions to support GP’s with this process.
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For those blocked earlier in puberty (tanner 2-4), a more gradual increase in hormones than is usually done in adults is recommended – see Endocrine society Guidelines 2017
A general review of effects and side effects of hormones, alongside physical review to include weight and blood pressure and height if still growing is usually done 3 monthly in the first year after initiating hormones and less frequently once at stable hormone dosing ie 6-12 monthly.
For Transmasculine young people blocked at tanner 2-4 GnRH agonists can usually be stopped once on full dose of masculinising hormones for 6-12 months.
For Transfeminine young people Gnrh agonists are considered gold standard in androgen blocking as they are very effective and have few side effects. They can be continued alongside oestrogen long term unless the adolescent wants to change to an alternative oral antiandrogen eg Cyproterone acetate or spironolactone (click here). Full discussion around the risks of benefits of changing to an alternative androgen blocking medicine would be needed.Those blocked at earlier tanner stages would usually continue on GnRH agonists as long as possible and potentially until orchiectomy .
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Masculinising Hormones
https://www.healthpoint.co.nz/public/sexual-health/hauora-tahine-pathways-to-transgender-healthcare/ consent form starting masculinising Hormones
https://www.transhub.org.au/hormones-masculinising
https://transcare.ucsf.edu/article/information-testosterone-hormone-therapy
https://www.transhub.org.au/changing-your-mind?rq=changing%20your#links
Feminising Hormones
https://www.healthpoint.co.nz/public/sexual-health/hauora-tahine-pathways-to-transgender-healthcare/ - see consent form starting feminising Hormones
https://www.transhub.org.au/hormones-feminising?rq=feminising%20Hormones%20
https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy
https://www.transhub.org.au/changing-your-mind?rq=changing%20your#links