UCSF Pediatric Focus

How to Tailor Care for Gender-Expansive Children, Teens and Young Adults

Shay was born looking like a typical girl, but by the age of 4, Shay had begun talking about “his” gender and refusing to wear dresses. “He told us he wanted to turn into a boy for his fifth birthday,” says his father, Wayne.

Shay is but one example of an emerging trend in the United States, in which unprecedented numbers of children, adolescents and young adults are seeking help and treatment related to their gender identity. This explains why it’s important to have services available that meet their unique health care needs, says Stephen Rosenthal, MD, medical director of the Child and Adolescent Gender Center (CAGC) Clinic at UCSF Benioff Children’s Hospital San Francisco.

Unique needs and increased demand were the driving forces behind the 2010 formation of the CAGC. A collaboration between UCSF and community organizations, the CAGC provides advocacy and legal support to transgender, nonbinary and gender-expansive children and adolescents, as well as comprehensive medical and psychological care through the CAGC clinics in San Francisco, Oakland and San Mateo, which the UCSF Division of Pediatric Endocrinology staffs and runs.

A Full Array of Services Is Essential

Because many gender-expansive youth and adolescents feel a strong conflict between their gender identity (their inner sense of who they are) and their physical sex characteristics, the CAGC clinics offer an array of services:

  • Medical management, which includes:
    • Carefully monitored and fully reversible puberty-blocking medication, which delays what can be confusing physical changes. Young people who experience significant anxiety and distress from a “mismatch” between their gender identity and their body can have extra time to come to grips with their feelings.
    • Cross-gender sex hormones when the clinic’s patients are old enough and emotionally prepared to make a decision about their gender identity.
    • Expertise in primary care and adolescent medicine to complement the pediatric endocrinology services and expertise highlighted above.
  • Psychosocial support. “It is not uncommon for our patients to have to simultaneously cope with the confusing changes of adolescence, difficult interactions at school and sometimes complex psychiatric issues,” says adolescent and young adult specialist Stanley Vance, MD, who assesses patients for everything from depression, substance abuse and eating disorders through emerging gender identity and sexuality. “It’s important to have a provider with experience managing these concerns, especially because adolescent development is a moving target.”

Providers at the clinic also coordinate care with outside primary care doctors, mental health providers and schools.

Helping Young Children and Families

Within those services, the approach can vary, often depending on the young person’s age. As was the case with Shay, transgender children often make their identity known at a very young age, and it is not always clear whether their desire to change gender will continue into adulthood.

Therefore, gender specialists like clinical psychologist Diane Ehrensaft, PhD, listen to verbal cues to carefully evaluate and diagnose these patients, including assessing whether they have clinical distress associated with their gender identity. It is a crucial role that demands expertise, because research has not yet definitively established the degree to which these feelings may change over time. “While we await the research, it’s essential that we provide evidence-based services that can help children and families navigate these complex challenges,” says Ivy Aslan, MD, medical director of the CAGC clinic at UCSF Benioff Children’s Hospital Oakland.

Medical Management and the Need for Ongoing Research

Once children hit puberty, their medical needs can become more complex. CAGC clinicians look to the Endocrine Society’s most recent clinical practice guidelines, which Rosenthal helped revise. The guidelines are based on graded, published evidence and on expert opinion. Much of the published data are drawn from studies in the Netherlands, which are the largest conducted to date. In particular, Dutch researchers pioneered the current approach to medical treatment, which first involves administering gonadotropin-releasing hormone agonists to block puberty.

“It’s like hitting a ‘pause button’ on puberty for these young people, and it can be very helpful,” says Rosenthal.

To advance understanding of just how helpful, in 2015 the UCSF CAGC and three other institutions received a $5.7 million grant from the National Institutes of Health to study the long-term effects of these types of medical treatments for transgender youth. It is the first such study in the U.S., and the resulting data should play an important role in optimizing medical care of transgender youth.

For more information, please call the Child and Adolescent Gender Center Clinic at the location nearest you:

  • UCSF Benioff Children’s Hospital San Francisco: 415-353-7337
  • UCSF Benioff Children’s Hospital Oakland: 510-428-3654
  • UCSF Benioff Children’s Hospital San Mateo Specialty Care Clinic: 650-685-8419