Gender Identity.docx

Gender identity: female/woman/man/male/other Gender expression: feminine/masculine Sex assigned at birth: male/female/intersex Gender diverse: gender behaviors, appearances, or identities are incongruent with those culturally assigned to their birth sex; individuals may identify as transgender, n...

Gender identity: female/woman/man/male/other Gender expression: feminine/masculine Sex assigned at birth: male/female/intersex Gender diverse: gender behaviors, appearances, or identities are incongruent with those culturally assigned to their birth sex; individuals may identify as transgender, non-binary, genderqueer, gender fluid etc. Gender fluidity: parents/caregivers first notice signs at 4.5 years old and children first recognized around age 6 Gender identity development pathways: 1. Early childhood: vocal is when TGD children who know their gender identity at an early age and vocalize their needs 2. Early childhood: silent is TGD children who know their gender identity at an early age but remain silent because of cues from family or others 3. Puberty: children who do not become aware of TFD identity until the beginning or middle of puberty Gender Identity development: 18-24 months: children develop ability to label gender 2-5 yrs old: most kids recognize gender differences, use gendered pronouns 6-10 yrs old: most children declare a gender identity of male or female by ages 5-6 - Exploring gender is a very normal part of development - Some children exhibit persistent, insistent, and consistent behaviors, expression and identity Presentation in Pre-pubertal children: - Preferred clothing, toys, dress that differ from gendered societal expectations - Statements: "I am not a boy" Support for Prepubertal Children: - No gender specific medical intervention at this time - Safe environment - No shaming - School support - Consult gender team for support and education - Play groups if available - Gender diverse books Presentation in Early Puberty: - Fear of developing masculine or feminine body - Confusion/conflation: gender identity and sexual orientation - Isolation, depression, anxiety, self-harm - Restrictive eating to preserve or alter body - Increased awareness, acknowledgement of gender discomfort Supporting Early Pubertal Youth: - Medical interventions like puberty blockers and menstrual suppression - Explore gender dysphoria vs anatomical dysphoria - Stress individual differences, fluidity, continuums - Normalize behaviors and feelings - Importance of family support Presentation in Pubertal Youth/Adolescents: - More nuanced understanding of gender identification - Increased online research and social media connections - Romantic relationship concerns - Increase or decrease in mental health issues - More clarity in gender expression: clothing, packing, tucking, binding Supporting pubertal youth/adolescents: - Development of treatment plan - Initiation of hormone therapy - Pursuance of surgery - Exploration of sexuality - Safe sex education and reproductive issues - Development of supportive networks in high school, college, and community Gender Dysmorphia/Incongruence: - Discomfort or distress from incongruence between one's gender identity and their sex assigned at birth, including both physical characteristics and gender role Non-affirming models: corrective - Goal is to align gender identity and expression with natal sex - Discourage gender diversity - Encourage gender normative play and preferences - Conversion therapy Non-affirming models: supportive - "wait and see" how gender identity unfolds - Neither discourage nor encourage gender-related behavior or expression - Unlikely to encourage social transition or medical intervention prior to puberty **Affirming Model: (the best)** - The goal is to understand and appreciate a child's gender experience - Assist youth and families in learning about and engaging in gender affirmation including social and medical interventions **Gender Affirmation** - Social affirmation: adopting gender-affirming hairstyles, clothing, name, pronouns. Can be done at any age and is reversible - Puberty blockers: GnRH agonists; give during puberty; reversible - Gender-affirming hormones: testosterone and estrogen plus androgen inhibitor; give early adolescent and onward; this is partially reversible - Legal affirmation: changing gender and name recorded on birth certificate; done at any age and is reversible **Puberty Blockers:** - GnRH agonists: leuprolide, histrelin - Historically used for precocious puberty - Can start at tanner stage II to III - Can be used up to around age 16 and concurrently with hormones - Would be referred to peds endocrinology - Benefits: completely reversible, allows exploration while distress is alleviated, decreased need for some future surgeries due to irreversible changes - Risks: minimal long-term side effects, Decreased height velocity, genital underdevelopment may limit potential Affirming Hormones: - Use of cross-sex hormones to allow adolescents who have initiated puberty to develop secondary sex characteristics of the opposite sex - Testosterone effect will overpower estrogen effect - Benefits: resolving dysphoria caused by secondary sex characteristics - Risks: foreclosure of fertility, requirement of additional tissues used in vaginoplasties **Masculinizing hormones:** - Testosterone - Goal serum testosterone: 400-800 ng/ml - Irreversible effect: lower pitch voice, increased facial and body hair growth, male pattern hair loss, genital changes - Reversible effects: acne, fat redistribution, increased muscle mass and upper body strength, increased libido, menstrual cessation, increased RBCs **Feminizing hormones:** - Estrogen: most commonly 17-beta estradiol via transdermal patch, oral, or SL plus the antiandrogen (usually spironolactone) - These do NOT cause voice pitch rise, decrease in laryngeal prominence, or dramatically affect facial hair - Irreversible effects: breast tissue growth, decreased testicle size, slowed body hair growth, slowed male pattern baldness - Reversible effects: skin softening, reduced muscle mass/upper body strength, fat redistribution (apple to pear), decreased libido, decreased erections, mood changes