Medical care for gender variant young people: Dealing with the practical problems

Although many clinicians, perhaps unknowingly, have young patients who experience gender variance, they will rarely encounter a case where the condition appears profound and persistent. Strong social pressures, within the family and at school, usually inhibit any revelation of gender variance. If families do identify the gender variance and seek medical help, the prudent response would be to refer the youngster to a specialised paediatric service that offers multidisciplinary care, provided by experienced mental health professionals and endocrinologists, in accordance with the internationally recognised standards of care. However, in many countries, there is no such service or the service available follows an approach that is unacceptable to the young people and their families. In that situation, the clinician faces a range of practical problems. At the prepubertal stage, even the most experienced mental health professionals cannot predict the likely persistence of the condition. However, at the onset of puberty, a reliable prognosis is often possible. Then, the clinical response in many advanced countries is to suspend puberty. That relieves the stress caused by bodily changes that conflict with the young person's gender identity. It also provides patients and clinicians with more time in which to confirm the prognosis, following which the alignment of the body with the gender identity can commence. Initially, this is achieved by the administration of cross-sex hormones. Ultimately, usually in adulthood, surgery is provided to complete the physical transformation. The clinician contemplating such a treatment pathway for an adolescent, needs to be aware of: the legal and ethical issues that relate to medical care for this patient group; the ongoing educational and support needs of the young person's family and school; the resourcefulness demonstrated by some parents, for instance in the UK, who, having been denied physical intervention for their adolescent child, obtain it in other countries; the ease with which young people denied such intervention can obtain information and medication via the internet, even paying for it by working in the sex trade; and, if the clinician decides to offer local care, the willingness of experienced clinicians in other countries to provide guidance. (C) 2008 Elsevier Masson SAS. All rights reserved.