Review of: Sorbara JC et al, Pediatrics 2020;146(4):e20193600

Gender incongruence means that a young person identifies with a gender that’s different from the one they were born with. These youths have an elevated risk of suicide and other psychiatric problems. Gender-affirming medical care (GAMC), such as hormonal therapies, can reduce those risks, but when is it best to start those treatments?

An earlier study found that psychiatric outcomes were better when youths began GAMC before age 12 compared to those who transitioned in adolescence. This newer study builds on this literature by examining the association of both age and pubertal stage at presentation for GAMC on mental health.

The researchers undertook a chart review of 300 patients at a Canadian clinic for transgender youths. They compared outcomes for two groups: those presenting before age 15 (n = 116, median age 14) and those presenting after age 15 (n = 184, median age 16). Most were assigned female at birth (75%), and the majority were Caucasian (72%). The rate of autism (6%) was higher than that of the general population.

Youths who started treatment after age 15 had higher rates of depression (46% vs 30%), self-harm (40% vs 28%), suicide attempts (17% vs 9%), and psychiatric medication use (36% vs 23%). They also recognized their gender incongruence later (median age 9 vs 6) and socially transitioned later (15 vs 13).

Stage of puberty at the time of starting hormones was even more predictive of problems than age. Late pubertal youths (Tanner Stage 4 or 5) were 4–5 times more likely to report depressive or anxiety disorders. The gender assigned at birth was also predictive, with those transitioning from female to male reporting a threefold higher rate of self-harm than those transitioning male to female. Older teens were more likely to be taking psychotropic medications.

The study’s main limitation is its uncontrolled design, which leaves open the possibility that the youths who presented later were already at risk for psychiatric problems. It may be that youths with more secure identities and supportive families are simply more likely to seek these services at a younger age.

CCPR’s Take
This field is complex. We have a lot to learn about such things as possible differences between patients who experience gender dysphoria earlier in life vs at or around puberty. Still, this study brings reassuring data for families who are considering gender-affirming hormones before the onset of puberty. Outcomes are apparently better when treatment is started before secondary sexual characteristics begin to develop.