Pediatric Annals

Special Issue Article 

The Reproductive Health Care of Transgender Young People: A Guide for Primary Care Providers

Nancy A. Dodson, MD, MPH; Miriam Langer, MD


Primary care providers should have a general understanding of the medical care available to transgender youth throughout childhood and adolescence. Providers and parents should create an affirming environment for young people at every developmental stage, while ensuring thorough and thoughtful evaluations prior to any medical intervention. Transgender teens have unique reproductive health care needs. Transgender boys may seek suppression of menses, and they will need to pay particular attention to pregnancy prevention if they decide to undergo masculinizing hormonal treatment. Transgender girls who undergo feminizing hormonal treatment will also see profound changes to their reproductive and sexual function. Providers should feel comfortable getting detailed sexual histories to properly counsel on and test for sexually transmitted infections. Finally, the effects of medical and surgical transition on a young person's potential for future fertility is a profoundly important concept for both the teen and their parents to understand. [Pediatr Ann. 2019;48(2):e64–e70.]


Primary care providers should have a general understanding of the medical care available to transgender youth throughout childhood and adolescence. Providers and parents should create an affirming environment for young people at every developmental stage, while ensuring thorough and thoughtful evaluations prior to any medical intervention. Transgender teens have unique reproductive health care needs. Transgender boys may seek suppression of menses, and they will need to pay particular attention to pregnancy prevention if they decide to undergo masculinizing hormonal treatment. Transgender girls who undergo feminizing hormonal treatment will also see profound changes to their reproductive and sexual function. Providers should feel comfortable getting detailed sexual histories to properly counsel on and test for sexually transmitted infections. Finally, the effects of medical and surgical transition on a young person's potential for future fertility is a profoundly important concept for both the teen and their parents to understand. [Pediatr Ann. 2019;48(2):e64–e70.]

An emerging issue in pediatric health care is the treatment of the transgender child and adolescent. Although prevalence data are difficult to come by, it is estimated that 0.7% of teens age 13 to 17 years identify as transgender, and that number is higher among preadolescents.1 A gender-affirmative model of care has replaced outdated notions of trying to repair or correct gender nonconforming behavior. In this article, we review a general approach to the transgender child as well a focus on the sexual and reproductive health care needs and concerns in transgender adolescents including gender-affirming hormones, menstrual suppression, contraception, sexually transmitted infection screening and fertility counseling, and preservation options.

Illustrative Case

A “13-year-6-month-old girl” presents to your primary care office. Her mother scheduled an appointment to discuss issues that have been going on at home. According to her mother, she has been unhappy with her body since puberty started (with thelarche) around age 11 years. When she developed breasts, she started to hide her body under baggy clothes. At age “12-years-6-month-old,” she had her first period, and found it extremely distressing even though it was not particularly heavy or painful.

Her mother notes that following menarche, she became more despondent. Just after turning age 13 years, she engaged in therapy and started to express that she feels “she is really a boy.” She told her mother and her therapist: “My body was a mistake. If I could re-do myself, I'd be a full biological male.” She had been reading on the Internet about transgender identities and feels that the term “trans boy” fits her well. Eventually, the patient asked her parents to use male pronouns, and began using a male-associated name.

The mother had been going to a support group for the parents of transgender adolescents and started to understand this concept. She has been going through old photo albums and noting how he played and has realized that “my child was a boy all along.”

You speak to the patient confidentially, using male pronouns as he requests. He says he always knew it didn't feel right when people called him a girl, and he always felt uncomfortable when he had to wear girlish clothes. When he developed breasts and started menstruating, this general feeling of “something's not right” transformed into, in his words, “complete horror.” He does not want to keep developing breasts and hips, and he does not want to menstruate again. He longs for a deep voice, a male physique, and above all, a flat chest.

His mother is seeking guidance about how best to help him. What can you tell your patient's mother about the care of transgender children? What reproductive health issues will you think about as you provide primary care for your patient in the coming years?

The Care of Gender-Nonconforming Prepubertal Children

Gender identity, or an innate sense of being male or female, tends to formulate in children around age 2 to 3 years. For most children, gender identity aligns with biologic sex—the male or female designation assigned at birth. Many children will display behaviors, clothing preferences, or play interests that more closely align with the opposite sex, and these children are often referred to as gender nonconforming. Table 1 presents terminology relevant to the subject of gender identity. Children whose innate gender identity differs from their assigned sex at birth can experience gender dysphoria—clinically significant distress resulting from this discrepancy. Even though prepubertal children are not candidates for any medical treatment, connecting them with a medical provider who specializes in gender management (either endocrinology or adolescent medicine) can help orient families to the landscape of gender nonconformity and help them respond to their children in a supportive, positive manner. Parents and providers can learn in-depth about the gender-affirmative model of care through guidelines such as the American Academy of Pediatrics' 2018 policy statement on comprehensive care for gender-diverse youth.1

Transgender Children and Adolescents: A Lexicona

Table 1.

Transgender Children and Adolescents: A Lexicon

Parents should be counseled to listen to their child and trust the child to know his or her own preferences for how to dress and what toys to play with. Knowing that gendered behavior and gender identity can change over the course of time, a child should still be believed and affirmed in the moment when they assert statements such as: “I don't like dresses,” “I want long hair,” or “I'm really a girl, not a boy”—the same way we would trust a gender-conforming or cisgender child to know their own gender and preferences. Parents should not feel pressured to discover their child's true, permanent gender identity while they are prepubertal; rather, they only need to listen carefully to the child and then honor their requests as long as they can do so safely.

When a child chooses to use a different name, and change their hair, clothing, room décor, and pronouns, this is referred to as a “social transition.” Social transitions may be partial (ie, just at home, just over the summer) or complete, depending on the wishes of the child and their community environment. This nonmedical intervention can be extremely powerful and beneficial for a gender-nonconforming child. Parental support for a social transition proves to children that they are loved and affirmed at least within the walls of their own home. Children who socially transition with parental support have mental health outcomes that are similar to their nontransgender age-matched peers.2

The Care of Peripubertal Transgender Children

At this time, puberty is the closest thing we have to a “test” as to whether a child's gender dysphoria will persist beyond childhood. Most children who are gender nonconforming will not be distressed by pubertal changes and will go on to identify with their birth gender, although they will often be nonheterosexual.3

A minority (often quoted at around 20%) of gender-nonconforming children will experience worsening distress during the physical changes of puberty.3,4 Other children who had no prior history of gender-nonconforming behavior will also experience gender dysphoria as their secondary sex characteristics develop. In addition to an adolescent medicine specialist or endocrinologist specializing in gender, a mental health provider with expertise in gender identity and adolescent development should join the adolescent's treatment team to help guide medical and social decisions moving forward. A summary of interventions can be found in Table 2.

A Developmentally Oriented Approach to Gender Affirmation

Table 2.

A Developmentally Oriented Approach to Gender Affirmation

Adolescents who identify as transgender and have been evaluated by mental health specialists may be candidates for medical interventions to more closely align their physical body with the gender identity. For peripubertal children who are at least in Tanner Stage 2, gonadotropin analogs (leuprolide injections or histrelin acetate implants) can halt a child's own puberty and the resulting distress that accompanies it. Even for adolescents who present in later Tanner Stages, the benefits of halting the remainder of puberty can be extremely beneficial.

The absence of sex steroids can have deleterious effects on bone density accrual,5 and so vitamin D and calcium intake should be maximized for teens on puberty blockers. Anecdotally, providers of transgender health care also note weight gain and low mood as common side effects. However, the relief at halting an unwanted puberty often outweighs these side effects, and adolescents are usually eager to continue pubertal suppression therapy.

The Care of Older Transgender Adolescents

Older teens may be candidates for transitional or gender-affirming hormonal care to undergo the development of secondary sex characteristics that align with their gender identity. The lower age limit for initiating gender-affirming hormonal care is a moving target; guidelines use to recommend age 16 years at a minimum, but experts now recognize the harms to bone health and social development of forcing a very delayed puberty on teens. Therefore, current guidelines recognize that teens as young as age 14 years may benefit from the initiation of gender-affirming hormones.6

Transgender Boys

For transgender boys, this involves masculinization therapy with regular testosterone injections. To mimic physiologic puberty and reduce side effects such as acne, mood changes, and erythrocytosis, patients start at a dose that is approximately one-quarter of a maintenance dose. The dose increases every 6 months until the patient reaches a maintenance dose about 1.5 to 2 years after initiation.6

It is useful for primary care providers to be familiar with the physical changes caused by transitional hormones. Transgender boys will see clitoral enlargement around 3 to 6 months after initiation of testosterone. Testosterone treatment can cause atrophy of the endometrium (thus leading to amenorrhea) and atrophy of the vagina. Patients may experience vaginal dryness (sometimes leading to spotting or bleeding), which can be treated with a topical estrogen cream if the patient desires. A study of the metabolic parameters of transgender men showed that they did not develop the metabolic features associated with polycystic ovary syndrome (such as dyslipidemia or insulin resistance) despite having high testosterone levels.7

Once serum testosterone levels are high enough, menses is likely to be suppressed indefinitely. For transgender boys on lower doses of testosterone (or who have not yet started hormonal treatment), addressing menses may be a priority. Attitudes toward menstruation vary among transgender boys; many find menses neutral or bothersome but not overly distressing.8 For many others, however, menses can be a source of significant dysphoria. In our experience, referring to bleeding as “endometrial bleeding” or “endometrial shedding” (as long as you clarify what this term refers to) may cause less dysphoria than the more female terms “menstrual bleeding” or “period.”

The first step in choosing a hormonal method of menstrual suppression is to discern what is most important to the patient. Is it near-perfect amenorrhea? Avoiding injections? A method the patient does not have to remember to adhere to daily? Choosing a method is a quality-of-life measure and thus there is no “wrong” choice.

Most trans boys will have a strong preference to choose an estrogen-free method to avoid worsening dysphoria. However, for those who are not averse to taking estrogen, a continuous regimen (skipping the placebo pills) of combined estrogen and progesterone is an effective way to achieve near-perfect amenorrhea.9 Any of the progestin-only contraceptive methods can help to decrease menstrual bleeding, although it is impossible to guarantee perfect amenorrhea. For most trans boys, knowing that they will experience significantly fewer days of bleeding, lighter bleeding overall, as well as the absence of cramps will do a great deal for their dysphoria.

For trans boys who are willing to undergo a short gynecologic procedure, a levonorgestral intrauterine device (IUD) is perhaps the best option for menstrual suppression. This procedure is best performed by an adolescent medicine provider, family medicine provider, or gynecologist with a trans-friendly practice; the procedure itself can cause worsening dysphoria and so a sensitive, patient, compassionate provider will have the best success. In our practice, we have had patients who needed two or three “false starts” before having successful placement of an IUD. Once placed, the patient can expect a short period of bleeding/spotting as the endometrium thins; followed by significantly reduced menstrual bleeding or frank amenorrhea. The levonorgestrel IUD also relieves cramps.

Medroxyprogesterone is an injection given every 11 to 13 weeks that can significantly reduce menstrual bleeding and induce amenorrhea within 3 to 4 injections. However, many patients experience prolonged bleeding after the first injection, which may be very distressing for trans boys. Medroxyprogesterone is associated with documented weight gain, particularly in teens who are overweight or obese,10 so it should be used with caution in those patients. However, for trans boys who are at risk of pregnancy but do not desire the IUD, the injection provides reliable contraception when injections are given on time. Injections can be timed with regular 3-month follow-up visits regarding gender dysphoria and gender-affirming care.

Progestin-only pills can help achieve amenorrhea, but they are time-sensitive and so teens with erratic schedules may have trouble taking them at the same time daily, which can lead to breakthrough bleeding. The progestin-only minipill is one option, but anecdotally, the risk for breakthrough bleeding is quite high. Norethindrone acetate can be used to achieve menstrual suppression; an initial dose of 5 mg daily can be increased to 10 mg, 15 mg, or even 20 mg daily to achieve menstrual suppression. Progestin-only pills are less reliable forms of contraception than depot medroxyprogesterone, the levonorgestrel IUD, or combined hormonal pills, and so they are not ideal for sexually active trans boys.

Other methods, such as the copper-containing IUD and the etonogestrel implant, do not reliably lessen menstrual bleeding. However, for patients who already have achieved amenorrhea due to testosterone, a copper-containing IUD may be an option for birth control. In a case series of three trans men, all had postplacement spotting or bleeding (and one patient had expulsion of the IUD with subsequent replacement) but eventually returned to amenorrhea and kept the IUD in for contraception.11

Chest masculinization surgery (“top surgery”) for trans men use to be an option only for those of legal age (usually age 18 years) but adolescents are undergoing top surgery at younger ages when they are deemed to be appropriate physical and psychological candidates. Research has found good outcomes regarding patient satisfaction even among younger patients.12

Transgender Girls

Transgender girls require a two-pronged approach to transitional hormonal treatment. They require estrogen, usually given in an oral form, to induce feminizing changes such as softening of skin, development of breasts, and redistribution of fat. Similar to testosterone, estrogen is prescribed in gradually increasing doses over a course of 1.5 to 2 years. Transgender girls also require an agent to block their own endogenous testosterone—either a gonadotropin analog such as leuprolide or histrelin acetate or an androgen blocker such as spironolactone. Transgender girls will experience decreased spontaneous erections and erectile dysfunction after a prolonged period on androgen blockers and/or estrogen therapy.

In general, surgery to remove gonads, genital surgeries, and hysterectomies are generally still deferred until legal adulthood.6 Trans women sometimes elect cosmetic surgeries to help them feminize further, such as feminizing laryngoplasty (to raise their voice) and facial contouring to lessen a square jaw and prominent brow.

Contraception Needs for Transgender Boys

Although testosterone can cause amenorrhea, it should never be considered a form of contraception. Unintended pregnancies have occurred on testosterone and this may be due to misinformation provided to patients; in one study, 16% of trans men believed that testosterone was a form of contraception, and 5.5% reported hearing this from their health care provider.13 Testosterone is classified as category X (contraindicated) during pregnancy, because a female fetus exposed to testosterone can have virilization of external genitalia. Therefore, any trans boy who is at risk of pregnancy must use effective contraception in addition to testosterone.

To assess pregnancy risk, it may be necessary to get very explicit details about your patient's sexual behaviors. Many trans boys will have partners that are agender or gender nonbinary or will make reference to their partners who are also trans boys as “he.” In our practice, we ask very frankly about the genitalia of sexual partners. If a sexual or romantic partner has a penis, then the patient is at risk of pregnancy.

Sexually Transmitted Infections in the Transgender Adolescent

As stated above, it is important to get frank details about your patient's sexual activity to counsel and test them appropriately for sexually transmitted infections. This may involve directly asking about the genitalia of their partners. For trans boys who are sexually active with genetic female partners exclusively, screening parameters for women who have sex with women should be followed. These patients have a risk for chlamydia, genital warts, human papillomavirus (HPV), herpes simplex viruses, and syphilis. Gonorrhea and HIV could feasibly be transmitted through bodily fluids but is rarely reported. Safer sex counseling for sexually active trans boys who are active with girls should cover the importance of barrier protection (condoms, dental dams) during sexual contact—condoms on sex toys used for penetration and avoiding contact with menstrual blood and genital lesions.14

For trans girls who are sexually active with genetic male patients, screening guidelines for men who have sex with men should be followed. This involves an examination of the penis for warts or discharge, and examination of the anal area for fissures and anorectal warts. Oropharyngeal and rectal screening tests for gonorrhea and chlamydia should be performed based on the patient's exposure history. Anal Pap tests (done in the same manner as cervical Pap tests) should be performed on patients of any gender who have receptive anal sex. HIV and syphilis testing should be performed annually.15 As with all adolescents, primary care providers should make every effort to vaccinate transgender adolescents against HPV.

Fertility Counselling for Transgender Adolescents

One of the risks of medical intervention for the treatment of gender dysphoria is compromised fertility. Gonadotropin-releasing hormone administration, although reversible, pauses gonadal maturation.16 Gender-affirming hormones are also believed to negatively affect gonadal function, although the long-term effects are largely unknown. Although pregnancy has been reported in trans men previously on testosterone,17 studies have shown that ovaries exposed to high level of testosterone fibrose, impairing oocyte release.18 In natal males, estrogen exposure leads to absence of Leydig cells in the testis and impaired spermatogenesis.19 Therefore, both the Endocrine Society Guidelines and World Professional Association for Transgender Health Standards of Care for the treatment of transgender patients recommend counseling on fertility and fertility preservation (FP) before initiating medical treatment, pubertal suppression, or hormones.6,20

FP methods available to transgender boys include ovarian tissue cryopreservation (OTC) or oocyte preservation. In OTC, ovarian tissue biopsy or unilateral oopherectomy is performed to preserve primary oocytes. This method is available to trans men regardless of Tanner stage, although, because the protocols are experimental, this option is only available at limited academic institutions. When the patient is ready to have a child, the preserved tissue can be used either for ovarian tissue transplantation or in vitro ovarian maturation. Thus far, there are over 50 reports of human live birth after tissue transplantation.21 Peripubertal or postpubertal trans boys can undergo oocyte retrieval, although protocols include 10 to 14 days of hormone injections and multiple transvaginal ultrasounds, both of which may heighten dysphoria. After retrieval of the oocytes, they must be stored frozen. Facilities charge to store the frozen specimens, which is costly even for just a few years and in these cases can be expected to be preserved for more than 10 years.

Trans women can achieve FP through cryopreservation of a semen or testicular sample. For prepubertal trans girls who do not have mature gametes, testicular tissue collection is their sole option, although it remains experimental, with some reported success. In pubertal trans girls, sperm can be obtained via manual ejaculation, electroejaculation, or surgical retrieval. Of note, ejaculation can exacerbate dysphoria and has been cited as a reason trans men do not opt for FP.20 Therefore, it is important to counsel on the various methods available for sperm collection.

Although the current recommendation is to counsel patients on FP options, reports are beginning to emerge that few trans youth pursue these options. Even when fertility counseling is routinely provided to these patients prior to initiation of therapy, few transgender youth use the FP services.22 Reasons given for declining fertility preservation include discomfort with masturbation to produce a semen sample, cost, and fertility centers not being welcoming to transgender people.23 However, little is known about transgender youth's attitudes toward having future biological children.

Research suggests that half of trans adults desire biological children and one center found rates of FP in transgender adults are more than 5 times higher than that of trans youth, possibly implying that adults and children have different attitudes toward FP.22 As such, despite low reported utilization rates, it is important to have informed discussions with families prior to initiating medical intervention.

Due both to the fact that primary care physicians have a long-standing relationship with the parent and patient and the new data that many subspecialists do not feel adequately trained in fertility counseling, the primary care physician is in a unique position to have this serious and sensitive conversation. In our clinical experience, a thorough discussion of fertility helps the parents feel more confident moving forward with treatment and helps the therapeutic relationship with parents. More thorough FP counseling will be provided by the reproductive endocrinologist, adolescent medicine specialist, or urologist to whom the patient will be referred if they express interest. Since it seems that opinions regarding fertility change with age and anecdotally as they engage in romantic relationships, in our practice, we repeat these conversations with patients periodically over time, even after treatment has begun.


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  20. Coleman EW, Bockting M, Cohen-Kettenis P, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Tansgenderism. 2012;13:165–232. doi:. doi:10.1080/15532739.2011.700873 [CrossRef]
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Transgender Children and Adolescents: A Lexicona


Sex: an assignment of male or female, made on the basis of genitalia, gonads, or chromosomes


Gender: an internal sense of being male or female that generally develops around age 2 years; this is a separate concept from sexual orientation, which refers to one's sexual attraction


Gender nonconforming or gender diverse: terms that describe a range of behaviors and presentations that deviate from culturally accepted gender norms; gender diversity exists along a continuum from adopting a single physical or behavioral characteristic of the opposite gender (ie, a boy who wears nail polish, a “tomboyish” girl) to fully presenting as the opposite gender


Transgender: people who have a fixed gender identity over time that differs from their assigned sex at birth


Transgender female: a person who was assigned a male sex at birth but identifies as a female


Transgender male: a person who was assigned a female sex at birth but identifies as a male


Cisgender: a person whose gender identity is the same as his or her assigned sex at birth


Gender nonbinary: a person whose gender identity cannot be classified by cisgender male, cisgender female, transgender male, or transgender female; rather, their identity exists along a spectrum from feminine to masculine and may remain fluid over time; such persons often prefer the gender-neutral pronouns “they/them”


Gender dysphoria: distress that results from the discrepancy between one's assigned sex and one's gender identity; often due to norms and expectations from society regarding gender roles and behaviors; not indicative of any mental illness or deficit on the part of the person


A Developmentally Oriented Approach to Gender Affirmation

Affirmation Definition Developmental Stage Care Team Involved Special Considerations
Social transition Changing name,a pronoun,a hairstyle, dress, bedroom décor; may be partial (ie, just at home, just over the summer) or complete Prepubertal children, peripubertal adolescents, older adolescents Family, pediatrician, school, transgender health specialist (adolescent medicine, endocrinology), gender therapist Important to give children a way back to their birth gender if they so desire (“let's see how you feel living as a girl right now”)
Pubertal suppression Gonadotropin-releasing hormone analogs given in either injection or implant form (leuprolide or histrelin acetate) to block the progression of puberty Peripubertal adolescents who are in Tanner Stages 2–5 Family, pediatrician, transgender health specialist, gender therapistb Maximize bone health by optimizing vitamin D levels and encouraging calcium intake
Height optimization Oxandrolone, an anabolic steroid with mild androgenic effect, can increase final height among trans boys; low-dose estrogen can fuse growth plates and decrease final height among trans girls Peripubertal adolescents in whom epiphyses have not fused, and in whom family and provider are relatively certain that desire for cross-gender affirmation will persist Family, pediatrician, transgender health specialist Given permanent effects on height, as well as the fact that height optimization interventions are not well-studied in the trans population, these should be pursued with caution and on a patient-by-patient basis
Transitional hormones (cross-gender hormones) For masculinizing therapy, testosterone given in either injection or topical gel form. For feminizing therapy, estrogen given in oral form along with androgen blockade (spironolactone or leuprolide) Adolescents who have had puberty suppressed and are at least age 14 years; postpubertal adolescents Family, transgender health provider, pediatrician, gender therapistb Induction of desired puberty begins with low doses of sex hormones that increase in a step-wise fashion over 2 years
Affirming surgery Top surgery (chest masculinization or breast augmentation), vaginoplasty or phalloplasty, facial contouring or feminization laryngoplasty for trans women Typically for legal adults (age 18 years or older) although chest masculinization surgeries are considered for younger teens on a patient-by-patient basis Family, transgender health provider, gender therapist,b surgeon with experience in gender-affirming surgeries (plastics, urology, and Ear, Nose and Throat) For adolescents who have had puberty suppressed since Tanner 2, all surgeries except for genital reconstruction may be deemed unnecessary

Nancy A. Dodson, MD, MPH, is an Assistant Professor of Pediatrics. Miriam Langer, MD, is an Adolescent Medicine Fellow. Both authors are affiliated with the Adolescent Medicine Division, Children's Hospital at Montefiore/Albert Einstein College of Medicine.

Address correspondence to Nancy A. Dodson, MD, MPH, Adolescent Medicine Division, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467; email:

Disclosure: The authors have no relevant financial relationships to disclose.


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