Full Length ArticleMenstrual considerations for transgender male and gender diverse adolescents who were assigned female at birth
Introduction
With greater public awareness of transgender (TG) issues over the past decade, more and more young people are disclosing their own gender identities and seeking medical care. One study from a North Carolina clinic reported a five-fold increase in young people presenting for transgender care between 2014 and 2018.1 In 2014 it was reported that 0.7% of youth between the ages of 13 and 17 years identified as TG, equaling 150,000 individuals.2 However, by 2019 the Centers for Disease Control and Prevention (CDC) increased the estimation, with 1.8% of high school students (275,000) identifying as TG on a youth risk behavior survey, and another 1.6% stating they were unsure of their gender status.3 To address the issues related to the needs of TG youth, the American Academy of Pediatrics (AAP) released a policy statement in 2018 specifically addressing the unique challenges that young people and their families may face, as well as to help guide pediatricians who will be called upon to answer these needs.4 Highlights of this position paper include that pediatricians need to provide culturally sensitive surveillance, support and care and be aware of the multiple health disparities and high-risk behaviors that may be present. Chief among these concerns are dysphoria, depression, anxiety and suicidality, that can be heightened with the onset of pubertal development, including menstruation. The goal of this article is to discuss menstrual issues that may impact TG youth, and therefore, unless otherwise specified, the focus will be on those assigned female at birth.
Section snippets
Terminology
Customarily at birth babies are identified as being of the male sex or female sex by visualization of their external genitalia, except in rare cases of intersex births. Sex, in this case, is a phenotype term as defined by the external genitalia, or at times by chromosomal analysis, but with it comes a lifetime of predetermined cultural, religious, and social expectations for that assigned sex. Gender, on the other hand, denotes one's inner feelings of self, as being male, female, both, neither,
Gender dysphoria and DSM-5 diagnosis
The term gender dysphoria, as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), represents an affective and cognitive disconnect with one's assigned sex (and therefore presumed gender) at birth.6 The DSM-5 categorizes Gender Dysphoria in Children separately from Gender Dysphoria in Adolescents and Adults. To meet criteria for Gender Dysphoria in Children, at least six of the following need to be met: 1. Strong desire to be the other gender or an insistence
Gonadotropin releasing hormone agonists (GnRHa)
To significantly improve the long-term health and well-being of TGD individuals, the use of a gonadotropin releasing hormone agonist (GnRHa) as a reversible first-line treatment is often used. GnRHas have been used since the early 1980s for the treatment of central precocious puberty in order to suppress the hypopituitary-ovarian axis via a negative feedback mechanism; GnRHas are also approved by the Food and Drug Administration for treatment of endometriosis, prostate cancer and uterine
Menstruation
As stated above, a hallmark of the persistence of a TGD identity is often increasing distress as one enters into or anticipates one's pubertal development. For individuals AFAB, this is often heralded by breast development and/or menstruation. While not all TGD-AFAB have menstrual dysphoria, it is a common concern among young people presenting for care. Menstruation is historically (and physiologically) a female concept related to normative reproductive expectations. The knowledge of the
Conclusions
Menstruation is a biologic function that is ingrained in society as a feminine normative experience.42 For women, the act of menstruation signals that one's body can function along typically expected processes involving fertility and pregnancy, but also requires attention regarding contraception and gynecologic issues. For transgender males or non-binary AFAB individuals, the start of menstruation as an adolescent or the anticipation of such, as well as menstruation in transgender adult males,
Declaration of Competing Interest
The authors do not have conflicts to declare.
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2022, Current Problems in Pediatric and Adolescent Health Care