Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care

Our PM is the initial point of contact for all families interested in establishing care with GSDP. The PM conducts the initial telephone intake and gathers background information about parental (or patient, if the patient is of majority age) concerns and clinical service needs, provides information about services offered by GSDP, and connects families to community-based legal, school, and/or supportive resources as indicated. Patients and families can establish clinical care with our program either through multidisciplinary GDC or direct referral to the behavioral health team. Clinical appointments are family initiated. Eligible patients are youth under 25 years of age, and parental participation is required for youth under the age of 18. Youth and families can access adjunctive services without pursuing clinical care with our providers.

GDC, a twice-monthly half-day clinic, has been the primary avenue through which patients establish clinical care in our program. Providing multidisciplinary services in GDC are our adolescent medicine physicians, APN, psychologists, and endocrinologist. All new patients are seen by a medical staff member (adolescent medicine physician, APN, or endocrinologist) and a psychologist together at their initial appointment, which allows for joint interviewing and limits the need for families to repeat gender and psychosocial histories. This model also facilitates close collaboration among medical and behavioral health staff following a patient's initial clinical visit. Our endocrinologist typically plays a consulting role in GDC, but due to patient volume acts as the primary GSDP physician for a small caseload of primarily early pubertal youth.

All parents and patients ages 12 years and older complete a battery of psychosocial and gender-specific measures (Tables 1–3) at their initial GDC appointment. Together with a clinical interview, these measures provide an overview of a patient's gender development and current understanding of gender identity, body satisfaction, level of support for gender diversity, and emotional and behavioral functioning. This initial appointment, lasting ∼1.5 h, including time to complete measures, does not represent a comprehensive diagnostic evaluation or evaluation of readiness for medical or surgical interventions. Instead, the aim of the appointment is to inform treatment planning by identifying the patient's and parents' treatment goals and collecting information about gender development and psychosocial functioning to guide clinical recommendations.

Patients and families have various goals for establishing care, with some seeking education on GD course and whether and when to consider a social or medical gender transition. In these cases, the initial GDC visit may include psychoeducation about gender development and gender diversity, description of consensus (or lack thereof) on social gender transition for prepubertal children with GD, and indications for medical intervention. Other patients, upon their initial visit to GDC, are already living in their affirmed gender role and are interested in pursuing medical transition. Care is made to individualize treatment recommendations based on clinical information obtained from the initial visit, which may include recommended follow-up with behavioral health staff (for therapy focused on gender exploration or evaluation of readiness for medical intervention) or medical staff (for psychoeducation regarding hormonal intervention).

For youth and families interested in initiating GnRHa or gender-affirming hormones, the initial visit includes a discussion of GDC protocol and, when indicated, our clinical practice of considering gender-affirming hormones for youth who are cognitively and emotionally prepared around the age of 14. This practice varies from the Endocrine Society recommendation to wait until around age 16 for hormone treatment.⁶ Our rationale is explained—delaying exposure to sex steroids may decrease bone density among those on GnRHa.¹⁴ In addition, by age 16 most adolescents will have reached pubertal maturity, and delaying a gender-congruent puberty among transgender youth who are emotionally and cognitively mature enough to assent to hormone treatment before age 16 may have negative emotional and social consequences. We describe the steps to be completed during medical follow-up appointments before starting treatment, including (1) a comprehensive medical history, physical examination, and laboratory work, and for those starting GnRHa, a bone age and DEXA scan, (2) psychoeducation regarding anticipated effects, timeline of changes, and risks of hormonal therapy, and (3) written informed consent from the patient and, if the patient is a minor, consent from the legal guardian(s). In minors for whom there is more than one legal guardian, we make an effort to obtain written consent from both guardians. When there is disagreement, our team provides direct support in navigating discussions with the goal of reaching consensus. When agreement is not possible and it is determined that the minor will suffer emotionally without intervention, we have accepted written consent from a single guardian. In certain instances, consultation with a hospital ethicist has been helpful.

In addition to medical follow-up, we describe the need for a letter documenting readiness for medical treatment per criteria outlined by WPATH⁸ from a licensed mental health provider with at least masters' level education. GSDP does not require patients to be engaged in therapy for a specific length of time, recognizing that ongoing therapy may not be clinically indicated for all patients presenting for medical transition, nor do we require that readiness assessments be conducted by GSDP behavioral health clinicians, although this option is offered. For patients in care with community-based clinicians, permission is obtained for GSDP behavioral health staff to collaborate on patient care, including ongoing consultation around conducting a readiness assessment. For patients without established community-based clinicians, families may choose to see a GSDP behavioral health clinician or obtain referrals for gender-affirming clinicians in the community. Medical follow-up typically occurs outside of GDC during general outpatient clinic hours; however, patients with psychiatric/psychosocial complexity typically follow up in GDC, where our psychologists are present to address emergent clinical needs.

In the 31 months since implementing this model, we have seen 220 patients in GDC with ∼10–12 new patients seen each month. Fifty-four patients (37 birth-assigned males) were ages 11 and under, 154 patients (59 birth-assigned males) were ages 12–18 years, and 12 patients (4 birth-assigned males) were ages 19 and older at the time of their initial appointment. Thirty-four patients have been started on GnRHa for pubertal suppression, 20 have been started on estrogen, and 62 have been started on testosterone.

As highlighted, the behavioral health team is comprised of two psychologists and a child–adolescent psychiatrist. Services offered by psychologists and the psychiatrist are available to patients up to age 25 and 18 years, respectively. Providers conduct comprehensive diagnostic evaluations typically ranging from 2 to 4 sessions, the results of which may inform ongoing psychotherapy within GSDP. These providers also share responsibilities in conducting services that may be adjunctive to behavioral healthcare patients are receiving elsewhere, including evaluations for GD and assessments of readiness for medical treatment. Referrals for comprehensive evaluations are either (1) recommended following an initial GDC appointment for patients without community-based clinicians who are exhibiting behavioral/emotional difficulties or in need of a readiness assessment for medical treatment or (2) family initiated, including those establishing care with GSDP through behavioral health services versus GDC and patients preferring to augment care with community-based clinicians with gender-specific services with GSDP behavioral health staff.

The program psychiatrist offers supportive psychotherapy with a focus on gender-related issues. The program psychologists also provide supportive therapy in addition to treating co-occurring psychiatric conditions with evidence-based approaches (e.g., cognitive behavioral therapy). In cases when both evidence-based therapy and psychopharmacotherapy are indicated, a psychologist and the psychiatrist may comprise a patient's treatment team—the psychologist serving as a primary therapist and the psychiatrist offering psychotropic medication management. To date, 103 patients have had initial clinical appointments with a GSDP behavioral health clinician outside of GDC. If and when these patients are interested in pursuing hormonal treatment, a referral is made to one of our medical staff to be scheduled outside of GDC.

Given a general lack of experience with treatment considerations specific to transgender youth, GSDP behavioral health clinicians have devoted efforts to building the capacity of practitioners in the Midwestern region. These efforts include the following:

In 2016, program psychologists developed a weekly therapy group for transgender and gender-questioning adolescents. The group is guided by a social cognitive model with topics germane to this age group, including gender identity exploration, expression, and disclosure, family relationships, adaptive coping, social and medical transition, and dating and relationships.

Some, but not all, transgender individuals desire gender-affirming surgical interventions. WPATH guidelines⁸ recommend that genital surgery be deferred until youth reach the legal age of majority, with more flexibility for minors pursuing gender-affirming chest surgery with parental consent. Many transmasculine patients presenting for care after pubertal maturity express a strong desire for chest surgery to reduce GD and improve body satisfaction. In 2015, our program partnered with a surgeon from Lurie Children's Division of Plastic and Reconstructive Surgery who has expertise in developmental breast anomalies to offer gender-affirming chest surgery and breast construction. To date, 24 patients have been seen for consultation and 7 have completed gender-affirming chest surgery. Program clinicians also make referrals to a local surgeon specializing in the full range of gender-affirming surgical procedures¹⁵ for patients ages 18 and older.

Many gender-affirming medical and surgical interventions available to transgender youth affect future fertility.¹⁶ Clinical practice guidelines^6,8 highlight the importance of discussing potential loss of fertility as a side effect of treatment. In response to patients' and families' concerns about potential loss of fertility, GSDP partnered with the Lurie Children's Fertility Preservation Team and Northwestern University's Oncofertility Consortium^* to routinely offer consultation and, if interested, fertility preservation services to patients before undergoing fertility compromising treatments. To date, nine patients have consulted with the Fertility Preservation Team nurse navigator, with two birth-assigned male patients pursuing sperm cryopreservation and one birth-assigned female patient pursuing oocyte cryopreservation.

Many gender-diverse youth and their families are socially isolated and lack supportive programming. To meet this need, the GSDP PM facilitates a monthly teen and parent night for gender-diverse youth ages 13+ and their parents. Parents engage in peer-based support, and guest speakers often join parents to present topics that are germane to supporting gender-diverse youth. Teens are provided with structured programming each month, such as sexual health 101 and panel discussions with transgender adults. Established in 2013, the group has grown from an average of 10 participants to more than 40 each month.

Many gender-diverse youth report dissatisfaction with voice quality. The WPATH Standards of Care⁸ highlight the clinical value of voice and communication therapy in alleviating GD and improving comfort with one's affirmed gender identity. In spring 2015, GSDP began offering an 8-week, group-based voice and communication therapy service for youth ages 12+. Formed in partnership with speech therapy faculty at Northwestern University's Center for Audiology, Speech, Language, and Learning, BeHeard's content focuses on improving aspects of verbal (e.g., pitch, resonance, intonation) and nonverbal communication (e.g., facial expression, posture, gestures).⁸

Transgender youth are more likely to experience body-related dissatisfaction compared with cisgender peers.¹⁷ Many transgender youth find exercising in public uncomfortable, and this discomfort may be compounded by lack of access to trans-friendly locker facilities. To address these issues, in summer 2016, GSDP will offer a physical wellness group to gender-diverse youth ages 14+. This weekly, 10-session physical wellness program focuses on developing personal wellness goals, increasing knowledge of cardiovascular and weight training techniques, improving nutrition practices, and facilitating social support. Each session, run by a personal trainer certified by the National Academy of Sports Medicine (NASM) and who has received cultural competence training from GSDP team members, will consist of 45 min of cardiovascular/weight training and 15 min of nutritional education.