13 year old born female trans male whose family is incredibly supportive, and the family is interested in learning more about hormone management. The patient has known for several years that something wasn’t right. He initially thought he was a female lesbian and told the family this about two years ago. About 1 year ago is when he came to the realization that he is actually transgender. He has been a patient with me for about 6 months and is incredibly shy, and speaks mostly through his parents. He has a very good relationship with them. They state there’s no sexual abuse history, and the patient is very reluctant to go to counseling and/or see other physicians (he’s just starting to “come around” to me.) As boarded in FM with very little endo in residency I’m unsure of the path for this, however, mental health is a huge part of my practice and I believe very important and I will be requiring this no matter the path forward.
What are the initial steps to take if he does become interested in hormone management?
Hi, thanks for the consult! Based on your description, this patient is an excellent candidate for GnRH analogs. Both Leuprolide (injection) and Histrelin (implant) will inhibit the Hypothalamic-Pituitary-Gonadal axis and thus stop menses. My interpretation of your clinical history is that this patient will ultimately end up on testosterone. Assuming that’s true, it will benefit the patient’s longer-term care to inhibit further female pubertal development, which itself can be very traumatic for TGNB adolescents. Thus a GnRH analog is preferable to an intervention that will focus only on preventing menses (e.g. OCs, LARCs, DMPA). Patients are typically left on a GnRH analog for two years, where there is evidence that long-term bone mineralization is not affected. You can leave the patient on the medication longer, but there is less evidence of its impact on future bone density. In the meanwhile, your intention to engage this patient in behavioral health services is appropriate. Especially given this patient’s shyness, it will be important to find a gender-affirming therapist who can create a supportive space where the patient can explore their gender freely. It will also allow his family to better understand and support his identity. If he does decide to pursue a hormonal transition, you can add low-dose testosterone to achieve a serum testosterone level appropriate for the patient’s Tanner stage. A typical starting dose is Testosterone cypionate injections of 25-50 mg (IM or SC) every two weeks to achieve this. Testosterone itself will suppress the H-P-G axis, so you can typically stop the GnRH analog between 6 and 12 months after starting testosterone without the re-emergence of menses. I hope this is helpful. Please let me know if you have additional questions!