When Stephen Rosenthal, M.D., director of pediatric endocrine clinics at UCSF Benioff Children’s Hospital, began seeing more requests for pubertal suppression or hormonal transition from young people who identified as transgender, he sought to better understand the condition known medically as gender identity disorder.

That pursuit led to development of a comprehensive center and clinic that offer these young people medical and psychological care, as well as advocacy and legal services that link them to support networks for a widely misunderstood condition. The principal clinic providers are Rosenthal, developmental psychologist Diane Ehrensaft, Ph.D., and Joel Baum, director of education and training at the advocacy group Gender Spectrum.

After three years as a virtual program of coordinated care, the clinic is now a monthly, physical reality at UCSF Benioff Children’s Hospital and a principal component of the newly formed Child and Adolescent Gender Center, which resulted, Rosenthal says, from the hard work of an eight-person steering committee.

The Need

The number of youths seeking to "transition" as they approach or enter puberty is rising. Studies on this patient population indicate that:

• In 70 percent to 95 percent of cases, the symptoms of gender identity disorder (GID) generally lessen or disappear as children enter puberty.
• When the condition does extend into puberty, however, it persists strongly in a very high percentage of these young people.
• Teens with persistent GID experience a high degree of psychiatric comorbidities, including depression, suicidal ideation and attempted suicide. But studies show that these conditions can be mitigated by familial acceptance and understanding.

Rosenthal says the findings argue for careful assessment and counseling as these young people enter puberty, and for increased medical understanding of the condition.

"Gender is not simply a psychological construct," Rosenthal says. "Recent studies indicate that transgender people have biological differences — including neuroanatomic and functional differences — in comparison to gender-conforming controls. Physicians who better understand the biology can help families with acceptance and access to appropriate treatment."

He and his team believe that being transgender is a normal variation in gender identity and that the American Psychiatric Association is expected to replace the term GID for transgender individuals with the term gender incongruence or gender dysphoria.

Treatment

Current guidelines for treatment suggest that:

• Mental health professionals work with youths entering puberty to sort out a gender-nonconforming diagnosis.
• Endocrinologists consider administration of gonadotropin-releasing hormone agonists (GnRH-As) that can safely suppress puberty. Fully reversible, this treatment can buy time while patients achieve greater self-awareness with respect to gender. If and when appropriate, physicians can add cross-gender sex hormones.

"Studies from Amsterdam indicate that people with gender dysphoria who received GnRH-As early had a much better quality of life than those who didn’t," Rosenthal says. He notes some concerns about the treatment's slowing bone mineral density development, but when cross-gender hormones are introduced, bone density development appears to return to normal.

"We're excited because our gender center is a true partnership between UCSF, the Bay Area community and others around the state to meet the needs of an underserved, misunderstood population,” says Rosenthal. "In addition to providing comprehensive services, our program will provide an infrastructure for research, and we hope it can be a model for others."

For more information, contact Dr. Stephen Rosenthal at (415) 476-2266 or rosenthals@peds.ucsf.edu.

Winter 2012 Table of Contents

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