The Dutch approach for transgender adolescents; past, present and future perspectives

Medical care for transgender adolescents including GnRH analogues (GnRHa) and sex hormone treatment under age 18 was started by Dutch clinicians and researchers three decades ago, after psychotherapeutic interventions were clinically observed not to be helpful in relieving gender dysphoria. This review aims to provide an overview of the Dutch reseach on transgender adolescent medical treatment since its start. Dutch studies evaluating a wide range of outcomes are summarized. Findings show relief of gender dysphoria, high appearance and treatment satisfaction and improved mental health, good self-esteem and general functioning, low sex hormone discontinuation rates and limited or no long-term consequences on growth of GnRHa followed by sex hormones and surgeries. Diminishing effects on bone mineral density (BMD) of GnRHa treatment are reversed in young adulthood with the exception of the lumbar spine in transwomen, which may be due to life style factors as untreated transwomen also have low lumbar BMD. Regarding neurodevelopment, the association between baseline IQ and completed education was similar in treated transgender adolescents compared to the general population. Sexual experiences are delayed but increase after gender-affirming care, and sexual functioning is not different in those starting with medical treatment in early puberty compared to late puberty stages. An early start of puberty suppression affects fertility options and fertility preservation counselling is therefore offered before start of early GAMT. Treatment from early puberty limits genital growth so that alternatives for penile inversion vaginoplasty may be necessary. Mastectomy at age 16–17 versus 18–20 years results in similar satisfaction and low decisional regret. Adolescents were found able to make informed decisions, but ethical challenges remain for which ethical support tools have been developed and moral case deliberations might be helpful. The increasing number of Dutch studies on GnRHa and sex hormone treatment for transgender adolescents allows a better assessment of both benefits and risks than was possible in earlier publications. In our view, the available studies support the provision of this treatment, while we acknowledge that more data are needed in several areas. Although findings are mostly reassuring, uncertainties still exist that require further research, which should include transgender adolescents’ perspectives and experiences.