Medical Implications of Gender Transitioning Therapy and Surgery

While gender transition medications/procedures aren’t services that our office offers, we still get questions from parents about the effects of these treatments on adolescents.  Based on these questions, we’ve looked into health implications for those who elect to undergo these treatments.  Here’s what we’ve found:
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Clinics that treat gender dysphoria have noticed some interesting trends in the number of adolescents identifying as trans in the last decade.  First, the number of adolescents identifying as trans has increased dramatically.  Second, gender clinics have seen a huge shift from primarily transfeminine patients (assigned male at birth) to a majority of transmasculine patients (assigned female at birth).  Historically, gender dysphoria presented in early childhood (ages 2 to 4) and was predominant in those born as boys.  Suddenly, we have seen a huge increase in individuals identifying as trans and instead of young boys with gender dysphoria, its adolescent girls with gender dysphoria.  So, what happened?  There are lots of possible explanations, from the influence of social media to the fact that it is more acceptable now adays to come out as trans.  The purpose of this blog is not to determine the reason behind this huge shift in demographics in the trans movement, but rather review the risks associated with medications for gender transitioning and surgery in adolescent natal girls.  What do these medications/surgeries do, are they permanent and what are the risks associated with taking them?

1. Puberty Blockers: When a girl enters puberty, her hypothalamus signals the pituitary which is a gland in the brain to send signals to the ovary to start producing hormones which will allow ovulation to occur (release of an egg from the ovary).  Puberty blockers usually a drug called Lupron, will shut down this entire process and prevent puberty from happening.  So, is this safe to do to a teenager who has not undergone puberty yet?  What are the risks?  First, these puberty blockers will stunt a teenage girl from growing in height and weight any further. She will likely be very short, as her longterm height will essentially be whatever height she is at time of beginning the medications.   It will also prevent breast formation, pubic hair/underarm hair and menstruation.  There is also concern that this will affect brain development and IQ as well.  Suppression of normal bone development also increases the risk of osteoporosis- her bones will be brittle, and she will more susceptible to fractures if she falls.  If a child moves from this to cross sex hormones like testosterone, the likelihood of becoming infertile is essentially guaranteed. 
2. Cross Sex Hormones: For teenage girls who have already been through puberty who are considering transitioning to male, the medication of choice is testosterone.  Testosterone does a lot of good things for mood, especially for someone who suffers from anxiety or depression.  It suppresses anxiety and lifts depression and produces a form of euphoria.  It makes you bold and unafraid.  It increases muscle mass and makes you stronger and increases your sex drive.  Testosterone redistributes fat away from the thighs and hips, and it causes body and facial hair to grow.  The girl will look like a boy.  It also causes severe vaginal atrophy (thinning, drying, inflammation of the vaginal walls that makes intercourse painful and can cause painful urinary symptoms as well).  After a few months on testosterone, the voice will crack just like an adolescent boy entering puberty), severe acne may follow, and even male pattern baldness.  It will cause the nose to become rounder and the jaw squarer.  Because testosterone thickens the blood, it increases the risk of having a heart attack by five times what a woman not on testosterone would have.  It also increases the risk of having a stroke, blood clots, and diabetes.  Testosterone also increases the risk of uterine cancer because of the effect it has on the lining of the uterus, and longterm use markedly increases the chances of permanent infertility.  Within several months after beginning testosterone, the changes to the body, like facial hair and voice changes, are all likely permanent.  These changes will persist even if she decides to transition back.    
3. “Top Surgery”:   For adolescents considering transitioning, the desire to proceed with bilateral mastectomy (removal of both breasts) is not uncommon.  One of the biggest misconceptions about this surgery, since breast augmentation is so common, is that if they change their mind, they can just get a “boob job”.  Unfortunately, this is not true.  Once the breast tissue is removed, if spacers are not placed at the time of removal (like we do for breast reconstruction following mastectomy for breast cancer), there is no way to do an augmentation that will look like real breasts again.  These individuals will also lose the ability to breastfeed it they ever decide to detransition or have a family.  Other risks include scar appearance, infection, seroma formation (where fluid accumulates and then drains), pain, bleeding, and distortion of the nipple. 

Hopefully, this blog helps to explain how gender transitioning medications and surgeries work as well as the risks involved for adolescent natal girls (born as a girl).  While we don’t feel that it’s our place to decide what’s best for your teen’s health, particularly regarding services that we don’t offer, we did want to provide patients and their parents (if the patients are minors) with information about the medical implications of these decisions.  Knowing about the potential side effects and being aware of the permanence of these therapies is important in making a well-informed decision that will affect their future. 
Dr. Pam