Medical Affirmation and Transition

Gender affirming medical care is necessary for some trans people. If your child is feeling distressed about their primary sex characteristics (e.g., wanting/not wanting a penis or vagina), or anxious about the changes that will come with puberty (e.g., breast growth, menses, voice change, facial hair), it is important to know what medical care options are available.

Care planning

Starting puberty blockers or hormone therapy, or having gender-affirming surgery are big decisions, and support from family and health care providers can be important in making them. Care planning may be provided by a number of professionals, provided they are trained to offer these services. These may include a pediatrician, family doctor, psychologist, psychiatrist, social worker or nurse practitioner.

The role of the care planner is to:

  • Provide timely, person-centered, strengths-based, trauma-informed, culturally safer, affirming care for children, youth, and families as they navigate their gender journeys

The following services may be provided, as needed:

  • Accurate, evidence-based information about gender health and care options
  • Comprehensive, collaborative, care plan development, including the following:
    • Gender health goals
    • Strengths, needs, and goals in the areas emotional, social, and family wellness
    • Plan to address gender, emotional, social, physical and/or family goals
    • Capacity of child or youth to provide informed consent for gender health care
    • Documentation of informed consent to care
    • Documentation of harm-reduction care needed/provided, if any
  • Referral for medical transition care:
    • Include care plan with the mental health clinician’s qualifications noted

Care planning is typically required before medical interventions are provided. One exception to a full care planning process may be prescribing hormones to a youth who is already taking hormones they have obtained through a non-prescribed source (e.g., from a friend, or on the street). The health care provider may prescribe hormones and provide safe injection supplies to reduce their risk of harm from contaminated drugs or needles. The provider will then work with the youth over time to ensure their gender goals are supported through a comprehensive care plan.

In the next section we will give a brief overview of the kinds of gender-affirming medical care available in BC, and link to pages on our website that provide more detailed information.

Puberty blockers

Puberty blockers are medications that suppress the sex hormones that are produced by the body. These medications may be started soon after puberty begins. They put puberty on pause and can prevent changes such as voice lowering, breast growth, and periods. Effects will vary, depending on how far puberty has progressed before starting the blockers. Puberty blockers are fully reversible, so if your child were to stop taking them their body would continue through puberty, picking up where it left off. These medications have been safely used for decades to treat children with precocious puberty, and were first used with trans youth in the 1990’s1. Research conducted since the year 2000 at a clinic in The Netherlands has shown positive outcomes for trans youth who chose to take puberty blockers2.

There are three main reasons that youth use puberty blockers. First, the onset of puberty and the idea or reality of developing secondary sex characteristics that do not fit with their gender identity can be very distressing. Puberty blockers can help alleviate this distress. Second, if a child is still exploring their gender, puberty blockers allow additional time to explore without worrying about unwanted physical changes. Lastly, preventing unwanted physical changes can eliminate the need for some surgeries and procedures later on, such as male chest contouring and electrolysis.

Puberty blockers are usually prescribed by a pediatric endocrinologist. Some pediatricians and GPs who are knowledgeable about trans care may provide this care as well. For more detailed information, both you and your child may be interested in our Puberty Blockers page.

Hormone therapy

Some youth who take puberty blockers early in adolescence go on to start hormone therapy. Youth who have not taken puberty blockers may also take hormones. Hormone therapy allows people to develop secondary sex characteristics that are in line with their gender identity, such as breast growth, softer skin, facial hair, or deeper voice. Common medications are estrogen and testosterone. Once these medications are started, changes happen gradually. Some are reversible and others are not, so we call hormone therapy a partially reversible intervention.

While not all trans youth will need hormone therapy, it is important that youth who do require this care have access to it. Like puberty blockers, hormone therapy can be effective in alleviating a person’s distress about their body and how they are perceived by others. Research shows that youth who have access to needed hormone therapy have mental health outcomes similar to their cisgender peers2, and a recent study documented that suicide attempts and emergency room visits decreased after trans youth had their first appointment with a pediatric endocrinology team at BC Children’s Hospital2.

Younger youth and their families/caregivers may work with a pediatric endocrinologist for their hormone therapy. Youth, especially those who are older, may be able to access this care through a knowledgeable family doctor. Family doctors can provide care planning, prescribing and monitoring of hormones, if they have training in this area. For more information on hormone therapy, please visit our Hormones page.

Gender-affirming surgeries

For some people, gender-affirming surgeries are important for living in their authentic gender. Bringing one’s body into alignment with the true gender self may be necessary for reducing distress. Some options include upper surgeries (e.g., breast augmentation, chest masculinization) and lower surgeries (e.g., hysterectomy/oophorectomy, orchiectomy, vaginoplasty, metoidioplasty, phalloplasty). A more complete description of surgery options, including those covered in British Columbia, please visit our Gender-Affirming Surgeries page.

Gender-affirming surgeries are called irreversible interventions, since the changes people’s bodies undergo cannot be undone. For the most part, people wait until they are at least 18 years old to have gender-affirming surgeries. However, chest masculinization surgery is sometime performed for youth under age 18.

British Columbia follows the WPATH guidelines for gender affirming surgeries. Part of this process includes surgical care planning with trained providers. For information on how to get a referral for a surgical care planning assessment, please Contact Us.

Decision making and consent for care

Young children typically depend on their parents to make decisions about health care for them. As they grow older, they assume greater responsibility for making health care decisions. A young person’s readiness to make health care decisions depends on several things, including their capacity to make these decisions and previous experience with health care decision making. No matter what age the young person is, supportive families are key in the health and wellbeing of trans youth. Ideally, youth and their families work together with health care providers to decide on a care plan that meets the youth’s need.

In British Columbia, the Infants Act states that minors have the right to consent to health care without their parent’s permission, provided two conditions are met4. First, the health care provider must be sure the youth understands the nature, consequences, risks and benefits of the health care being offered. Second the provider must determine that the care is in the best interest of the youth.

We know that access to medically necessary transition care, such as hormone therapy, can be life-saving for trans youth. Therefore, we support youth in making decisions about the health care that they need and work as hard as we can to help families to be supportive of their youth. Our goal is to ensure all youth and families have access to the psychosocial supports and medical care that allow the youth to live fully affirmed in their authentic gender self.

If you have a GP or pediatrician who is needing additional resources or support to provide care for your family around your young person’s gender health. please share the following information with them:

Rapid Access to Consultative Expertise (R.A.C.E.) Line

Physicians and nurse practitioners providing medical care to trans patients in BC can call a free consultation line. The Rapid Access to Consultative Expertise (R.A.C.E.) Line is staffed by physicians who are experts in trans health care. They are happy to answer questions so that practitioners can provide the best possible gender-affirming care for their patients. The R.A.C.E. Line is available Monday through Friday, from 8:00 a.m. to 5:00 p.m., at 604-696-2131 or 1-877-696-2131.

TCBC Care Coordination Team

Trans Care BC has a Care Coordination Team made up of a general practitioner (GP), nurses, and health navigators. They work with families and health care providers. For health care providers the offer support and clinical consultation around the delivery of gender-affirming care and connection to appropriate resources. The Care Coordination Team can be reached Monday through Friday, from 8:30 a.m. to 4:30 p.m. at 1-866-999-1514.

What’s Next?

In Navigating Systems of Care in BC, we outline how to access psychosocial and medical care in different parts of the province.

Resources

Books

Brill, S. A., & Pepper, R. (2008). The Transgender Child: A Handbook for Families and Professionals. San Francisco, CA: Cleis Press.

Online

Medical care information – Kids in the House, Johana Olson, MD (pediatrician)
BC Children’s Hospital Transgender Clinic
Puberty Blockers – Trans Care BC
Hormones – Trans Care BC
Gender-Affirming Surgeries – Trans Care BC

Articles

1 Cohen-Kettenis, P. T., & Goozen, S. H. M. van. (1998). Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. European Child & Adolescent Psychiatry, 7(4), 246–248. http://doi.org/10.1007/s007870050073
2 de Vries, A. L. C. de, McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. http://doi.org/10.1542/peds.2013-2958
3 Khatchadourian, K., Amed, S., & Metzger, D. L. (2014). Clinical management of youth with gender dysphoria in vancouver. The Journal of Pediatrics, 164(4), 906–911. http://doi.org/10.1016/j.jpeds.2013.10.068
4 Province of British Columbia. (1996). Infants Act. Crown Publications. Retrieved from http://www.bclaws.ca/civix/document/id/complete/statreg/96223_01