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as a Spectrum:

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Possible Interventions for Navigating Your
Child’s Gender Journey
Bianca Salvetti, MSN, CNS, CPNP
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Center for Trans Youth Health &
Development
on of Adolescent & Young Adult Medicine Children’s Hospital Los Angeles

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Developed in 2012

• Started seeing pts in 1994

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Current # of Patients: over
1800

Ages 3-25

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Services offered:

Medical care

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• Case Management
• Mental Health
• Social Support Groups
• Family Support Groups

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 THE DAILYGender
WIRE Dysphoria

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DSM -5
• Change from Gender Identity Disorder (DSM-4) to Gender
Dysphoria

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• Historically a barrier to care (still can be)
• Used for accessing care & services through insurance
• Receiving “diagnosis” may be pathologizing and stigmatizing
Diagnosis In Adolescents (children have different criteria)

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• Does person have history of identifying as their stated gender for
greater than 6 months (persistent)?
• Does person identify as their stated gender across situations and

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time (consistent)?
• Does person emphatically assert their identified gender
(insistent)?

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 THE DAILY WIRE Gender Dysphoria (GD)

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• General Presentation:
– Irritability, frustration, anger
– Can present as depression, anxiety, ADHD, bipolar,
etc.

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– Expression of a different gender
Presentation In Youth:
– Gender “nonconformity”

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• Clothing, toys, name, pronouns, hair, pee
standing/sitting
• Presentation In Adolescents:
– Distress with onset of puberty (Menses, chest, hair,

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voice)
– Drop in school/social functioning

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 THE DAILY WIRE Gender Dysphoria (GD)

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Wide range in presentation and stability
Constant from early childhood
Present early, remits during puberty
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Begins in puberty or later in life

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This can lead to doubt by families regarding gender
dysphoria

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American Academy of Pediatrics

“Research shows that regardless of developmental stage,

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prepubertal children who assert a [transgender or gender
diverse] identity know their gender as clearly and consistently
as their developmentally equivalent peers”

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“Attempts at predicting or changing who a child may become
have shown to be unsuccessful, and even harmful”

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“Being transgender is not contagious. Some youth may not have
confronted or feel they have to suppress gender diverse traits

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until they find nonjudgmental and affirming peers or online
communities that provide exposure to a wider range of gender
identities and expressions.”
AAP, 2018

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Persistence vs Desistence??

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• Prior studies have estimated that 2-27% of those with
childhood gender dysphoria have persistent gender
dysphoria in adolescents and young adulthood. Many

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flaws:
– These studies used different criteria for diagnosis
– They assumed those who did not return to clinic “desisted”

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– Follow-up was limited to 14-18 years of age

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Persistence vs Desistence??

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• Some important points:
– Intensity of GD in childhood is a predictor of “persistence” 2-3

– “explicitly asking children with gender dysphoria with which

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sex [gender] they identify seems to be of great value in
predicting a future outcome” 3

“Current approaches to care recommend that care

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•
providers prioritize young people’s stated identities,
perceptions, and needs in the present moment, as
opposed to attempting to estimate the likelihood of

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future identity and needs.” 4

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CHLA CTYHD Model of Care

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• Patient-Centered
– Gender care is unique to each patient
– Individualized care for each patient’s needs

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– The patient is the keeper of their own identity

• Informed Consent Model

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– The gatekeeper model is not evidence-based and was
designed to protect providers instead of patients
– Patients are given all information regarding treatments

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– The patient (and parents if <18) along with the provider
can then make informed decisions about how to support
the youth

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Gender Journey
Options
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Current Interventions

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Social transition
Psychosocial support
Medications Fully

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Reversible

– Puberty Blockers

– Feminizing Hormones Partially

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Reversible
– Masculinizing Hormones
Procedures

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Permanent (Possibly

Surgeries partially Reversible)

AdvancedReportingTimes.WordPress.com

Important- there is NO correct pathway to

transition!
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 THE DAILY WIRE Social Transition

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Safety is paramount
• Changes in areas of social interaction to decrease
distress
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Name/Pronouns
Hair Style
Clothing
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Toys
Activities
Let the youth lead and provide support

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Enhancing Gender Presentation
Trans Feminine

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– Tucking
– Breast Forms
Trans Masculine

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– Binding
– Packing/Stand-to-Pee Device
• For All

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– Hair
– Makeup
– Clothing
– Vocal training

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 THE DAILY WIRE Legal Transition

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Non-Binary Gender marker for CA documents
Federal documents still require either male or female

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gender marker

• No doctor’s letter needed for court decree

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CA – do not need surgery
Documents vary by state

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Fee Waiver

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Psychosocial Support

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Gender therapy for patient support

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recommended
(NOT required)
• Support groups for families

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• Parent/sibling individual therapy
• Discussions with schools

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• Changing name/gender marker on
school documents, access to
bathrooms

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Medical Interventions
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Medications – Puberty Blockers

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• GnRH Analogs given at steady state
“turn off” receptors in the pituitary
and “shut down” the HPG axis

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• Reversible “pause button” on
puberty
• Started once the patient is in at least

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Tanner Stage II

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•
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Histrelin implant (Subcutaneous (SQ): 12-24 months
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Leuprolide acetate injections (Intramuscular
(IM)/SQ): daily to every 4 months (typically use 3
month option)
Benefits

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– Improved quality of life
– Limits need for surgical interventions
– Gender concordant puberty
Price prohibitive
- Implant $5-30k

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• Side effects - Injection $3k/3m
– Hot flashes & Emotional lability (similar to menopause – does not
occur for everyone)
– Irregular vaginal bleeding (some people may continue spotting; some
can have heavy cycle before stopping completely)
– Site Infection

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— Possible bone density loss (will monitor bone density if planning on
using for >2years without adding hormones)
— Loss of fertility (if started in puberty early and/or if going on hormones
– see slide 23 & 24)
— Weight gain

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 THE DAILY WIRE Alternative Options
• Testosterone Blockers: Bicalutamide, Spironolactone

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(Both oral)
Can be used as bridge until approval of Puberty Blocker
No further masculinization
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Can cause permanent breast development
Will limit height, as estrogen is still being made so
growth plates can close earlier

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• Menstrual Suppression: Norethindrone (pill), Depo
Provera(injection), Nexplanon (implant), Intra Uterine

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Device
– No masculinizing effects
– Feminization continues (chest development, curves)
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 THE DAILY WIRE Masculinizing Medications
Testosterone Cypionate/Enanthate (SQ or IM) or Topical

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Testosterone (Gel, Patch)

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male-pattern
baldness

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clitoral
growth
↑ libido

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• At full dose, testosterone will stop menses on its own
• At lower dose, may also require a medication for menstrual
suppression if the patient desires (prefer progesterone only)

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Medications – Feminizing Hormones

• 17𝝱-Estradiol (SL/PO, Patch) daily or Estradiol Valerate (SQ every

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week or IM every 2 weeks)
Do NOT use Ethinyl Estradiol due to increased risk of blood clots

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↓ testicular size
↓ libido
↓ spont. erections
↓ sperm
production

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• Bicalutamide daily or Spironolactone BID (Oral) – block Testosterone
(Do not need these, because estrogen & progesterone can lower testosterone
over time. But many want to see changes ASAP, which this can help with).
• +/- Progesterone nightly (Oral) – augment breast development

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Medications – Fertility Considerations

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• Fertility Preservation Options:
– Egg Cryopreservation
– Sperm Cryopreservation

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• Require development to
Tanner Stage IV-V
• Process can be dysphoria-

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inducing
• Considered Experimental:

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– Ovarian tissue cryopreservation
– Testicular tissue cryopreservation

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Medications – Fertility Considerations

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• Puberty Blockers:
– If used alone, fully reversible including fertility
– If used early and add hormones later, likely no fertility?

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• Masculinizing Hormones:
– If patient has had menarche, fertility likely maintained
– Still possible to become pregnant on Testosterone

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– To keep pregnancy would need to stop Testosterone
• Feminizing Hormones:

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– Sperm production and testicular size decrease
– Current research suggests testicular tissue is not damaged
– Unknown if fertility would return if medication stopped

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Management Considerations

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1. Areas of distress for the patient
2. Patient goals for treatment

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3. Tanner Stage of the patient
4. Peer Concordance

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5. Growth potential of the patient

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Considerations: 1. Possible Areas of
Distress

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Pre-Pubertal

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– Name
– Pronouns
– Hair Style
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Clothing
Toys
Activities
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Genitals
DiagnoseMyLife.WordPress.com

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Considerations: 1. Possible Areas of
Distress

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Transmasculine

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– Name/Pronouns
– Chest Dysphoria
– Menstrual Dysphoria

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– Voice Dysphoria
– Height Dysphoria
– Hip Dysphoria

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– Facial Dysphoria
– Genital Dysphoria
ArtemisIllustration.tumblr.com

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Considerations: 1. Possible Areas of
Distress

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Transfeminine

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– Name/Pronouns
– Genital Dysphoria
– Facial Dysphoria

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– Hair Dysphoria
– Voice Dysphoria
– Height Dysphoria

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– Breast Dysphoria Foervraengd.tumblr.com
– Hand/Foot Dysphoria

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Considerations: 2. Patient Goals

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• For social transition, letting the patient lead the family,
school, etc. and providing support

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• For medical interventions, focused on areas of physical
distress

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– Based on patient goals
– Interventions are chosen to facilitate physical changes
that may result in decreased distress/dysphoria
– This applies to puberty blockers, hormones, and surgical

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procedures

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Considerations: 3. Tanner Stage

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• Tanner Stage determines if medical interventions are
indicated

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• Tanner Stage I (pre-pubertal): No medical interventions are
indicated
– Psychosocial Support

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– +/- Social Transition
• Tanner Stage II-V: In addition, medical interventions may
be indicated
– Puberty Blockers

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– Hormones
– Surgeries

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Considerations: 4. Peer Concordance
• One goal is to create as close to a peer-

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concordant puberty as possible
• This is different than some guideline
recommendations

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– For example, waiting until 16 for
hormones.
• Transmasculine individuals may be
gendered by others as male based

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on gender expression, but based on
higher voice pitch and lack of
facial hair, may be assumed by
others to be much younger (or to

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correct their ‘male’ assumption)
• BUT, a full beard at 12 is also not
peer concordant

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Considerations: 4. Peer Concordance

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Assigned Males

Trans-

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Voice Pitch
masculine Changes
(SMR 3-4)

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Facial Hair
Growth (SMR 4, 2
years after pubic
hair)

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Considerations (AMAB): 4. Peer
Concordance 6

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Assigned Females

Trans-

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feminine

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Considerations: 5. Growth Potential 7

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• Early Puberty:
– Increased sex hormones stimulate height growth
• Late Puberty:

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– Higher estrogen levels or conversion of testosterone to estrogen
inhibit further linear growth
• Estrogen fuses the growth plates in all genders

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• If Growth Is Not Possible/Wanted:
– Use higher doses of hormones to simulate “late puberty”
• If Growth Is Possible/Wanted:

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– Use lower doses of hormones to simulate “early puberty”
– May need another medication for cycle suppression

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Insurance coverage/authorizations
Procedures & Surgery

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– Coverage required in California if covered for cisgender people
Hormones
– Depending on surgery may not need to take at all or for certain

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amount of time
• Surgeries that remove ovaries or testicles – require hormone use x
1yr
• Breast augmentation – recommended to wait until 2yrs+ on

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hormones
• Chest surgery is covered in minors
• Support Letters required for insurance coverage

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– 1 letter from MH provider - above the waist
– 2 letters from MH providers – below the waist

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 THE DAILY WIRE Resources – Medical Care

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• CHLA Center for Transyouth Health and Development
– http://www.chla.org/transyouth
• UCSF Center of Excellence for Transgender Health

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– http://Transcare.ucsf.edu
• World Professional Association of Transgender Health
– http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,
%20V7%20Full%20Book.pdf

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• Trans Youth Care in SoCal
– CHLA, UCLA, CHOC

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• Adult Care
– UCLA, St. Johns, LGBT Center LA, Planned Parenthood

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Resources – Family/School Support

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• Family Acceptance Project
– http://familyproject.sfsu.edu

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• GSA Network
– http://www.gsanetwork.org
• Transforming Family

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– http://www.transformingfamily.org/
• Gender Spectrum
– https://www.genderspectrum.org/

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Resources – Social Support/Therapy

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• LA Gender Center
– https://www.lagendercenter.org/
• Trans Lounge (LGBT Center LA)

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– https://translounge.org/
• Colors LGBT Counseling (Antioch
University)

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– https://www.colorsyouth.org/
• Trans Wellness Center
– https://mytranswellness.org/

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• Trans Lifeline
– https://www.translifeline.org/

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 THE DAILY WIRE Resources - Legal

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• Lambda Legal
– https://www.lambdalegal.org/
• Transgender Law Center

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– https://transgenderlawcenter.org/
• National Center for Transgender Equality

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– https://transequality.org/
• Bet Tzedek
– https://www.bettzedek.org/

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THANK YOU! WIRE
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Bianca Salvetti

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