Hello and welcome to the session on transgender care comprehensive assessment for a multifaceted condition. My name is Stephen Rosenthal. I'm a pediatric endocrinologist and professor of pediatrics at University of California, San Francisco, and I also serve as the medical director of the UCSF Child and Adolescent Gender Center. I'd now like to introduce my co-host, Dr. Veronica Maric. Veronica. Thank you, Stephen. I am Veronica Maric, member of the annual steering committee, and I am delighted to co-chair this session with Stephen. I'm also a pediatric endocrinologist and I work at the Institute of Maternal and Child Research at the University of Chile, Santiago, Chile. Thank you, Veronica. So just a couple of general comments before we get started. I'm very excited to share with you what I just learned from our president, that there are 7,240 total scientific registrants at this year's endocrine society meeting. So this is really quite remarkable and wonderful. I'd also like to make sure you know that there will be a live Q&A after each of the three sessions. So please be sure to submit your questions during each of the sessions. Okay, so we have a very exciting symposium with three outstanding speakers. So let's get started with our first presentation, which will be delivered by Dr. Thomas Steensma. Dr. Steensma is a clinical psychologist at the Center of Expertise on Gender Dysphoria and the Department of Medical Psychology at Amsterdam University Medical Center. There, he works with people with gender incongruence and differences in sex development of all ages. Besides his clinical work, he's principal investigator in his department, where his research is primarily focused on psychosexual development, gender identity development, and treatment evaluation. Thomas has published numerous research articles in top-tier journals that have had a great impact on clinical care. The title of Dr. Steensma's presentation is Psychosocial Assessment, a Key Component in the Care to Transgender Youth. Please, Dr. Steensma. Thank you for the introduction. It's a pleasure to be part of this symposium and I'd like to thank the Endocrine Society for the invitation. So today I will talk about the importance of psychosocial assessment. I will talk about what we do in psychosocial assessment and focus on the role of the mental health practitioner in transgender care in youth. So I have nothing to disclose and I would like to start with some definition. So when we talk about sex in this symposium, we refer to the physical aspects of the assigned sex, chromosomal and anatomical characteristics. And when we talk about gender, it is about how one feels and identifies and the psychosocial aspects of the assigned sex. And gender is good to be distinct. It's good to distinguish gender role and gender identity. So gender role is about the behaviors, interests, preferences, personality traits that are stereotypically in certain cultures or societies. So they are different all over the world. Being a male in one side of the world is being is something else of being a male in the other side of the world. And gender identity, the subjective feeling of belonging to one of both genders or another. And then it's interesting that gender role and gender identity do not necessarily have to be in line with each other. So someone may express certain behaviors, but it doesn't necessarily say something about how they identify. That's really a subjective feeling. If someone experienced an incongruence between the assigned and experienced gender, we talk about gender incongruence or how it's described in the diagnostic and statistical manual of mental health and gender dysphoria. So gender incongruence is described in the ICD-11 and in the previous version of the ICD-10. It was labeled as transsexualism, but luckily that will change soon. So the last decade, we have seen a very sharp increase in attention, recognition and acceptance for the trans population. And they are clearly visible in gender identity clinics where we see a very sharp increase in referrals. But it will also result in more visibility in general hospitals. So all health care professionals will be confronted more and more often with the trans population. So this underlines the importance of this symposium that people are getting more familiar with this population. So as I said, the chart shows that since 2013, we see a very sharp increase in referrals in the Amsterdam Clinic for both adults and children and adolescents. And it's clearly amazing that this is a worldwide phenomenon where it's also happened all around the same time, 2013, 2013, 2014, where we see a sharp increase in all other clinics worldwide. So let's focus on the role of the mental health professional. It's good to make a distinction of the counseling in childhood, so pre-pubertal children, and the counseling of adolescents. When it is about counseling in childhood, there is no need for medical interventions because there's no pubertal development and medical interventions are not provided in childhood. But from a psychological perspective, it's also a good argument not to do it because children with gender incongruence, like all children, are in development. And what we see from clinical experience and studies is that the majority of children with gender incongruence will not develop or will not grow into adolescence or adulthood with gender incongruence. So they do not necessarily need a gender-affirming treatment in the future. But we've seen that children with gender incongruence, a large part of the group, will feel comfortable with their body and may identify more in an LGB sexual orientation, but do not necessarily treatment. So the focus of the mental health professional is primarily creating a safe and open environment for exploration for the child, counseling of possible uncertainty about the gender incongruence and the uncertainty about the future, and providing care and support for coexisting problems like coming from social stigma or self-esteem problems. So when it's about adolescence and things generally change when children grow up and they get into puberty, so there's more report of body distress, there's more distress about the gender incongruence. So adolescents who are getting referred generally have a better understanding of their needs, but still there's also quite a large group who really wants to explore their gender and explore the possibilities of treatment and explore their needs. And we want to find out what their burden and capacity is and their psychological function before we make these decisions. And when we make these decisions, the role of the mental health professional is focused on preparing and evaluating the social steps or medical steps taken. So if you think about assessment, assessment in transgender care is an ongoing diagnostic process where you first start with getting a very clear picture, but by taking steps you evaluate those steps, which gives you more diagnostic information about the future steps to take or the needs. So in my care practice I often draw stairs, and it helps me explaining for the adolescents and parents what our focus is or how we counsel and how we want to find out who they are. So we want to start with understanding and finding out what their gender incongruence is, how did it develop and where is the struggle, how do they function on a broader level, what is their broader functioning, and we want to know this first before we take decisions about coming out, a social transition, gender affirming hormones, or gender affirming surgeries. And finally, since 2000, we have the opportunity to relieve the adolescents after we have to get to know them with puberty suppression, so it lowers the distress of a developing body, so it buys time so we can find out what the needs are. So it's an ongoing process, and it's good to mention that a stair is different for everyone, and every step in the stairs is a stairway in itself, so we really do it step by step and evaluate it with the adolescents, how they feel and what their needs are. We present it in a more formal way, we always start with a first diagnostic phase where no medical interventions are provided. Then we have, if gender incongruence is present, and we think it will relieve the adolescent, we have the option of puberty suppression, and then later on we have the option in a second diagnostic phase to introduce gender affirming hormones and gender affirming surgeries later on. Dr. Hanama will get into more detail on the medical part of this protocol in the next presentation. So, when we think about assessment or talk about assessment we of course are very focused on the gender identity of the adolescents where we focus on gender development their body image, and their possible treatment desires they already have when they come in. And beside that we, we try to get a very broad view on their psychological functioning, their vulnerabilities, their strengths, their social functioning, their acceptance, or the stigmatization they experience, the support, but also the minority stress they may experience of having gender incongruence, or the stigmatization from the outside world, where it clearly can be a struggle. We are also focused on psychosexual functioning where we are very focused on their sexual development, and the future expectation and what the relation will be with certain treatment steps and the effect on their sexuality. And besides getting a lot of information from the adolescent and the family. We are also focused on providing a lot of information providing information about the treatment, the pros and cons, and how the adolescent things how they will deal with these pros and cons, and talk about physical functioning lifestyle and cognitive functioning the psychological maturation and the ability to make these decisions that can be life changing, and can be like having a huge impact on life. So, let me focus on where we focus on in gender identity. And of course we are focused on current and gender identity where we in Amsterdam generally use the DSM five, and the two of the criteria below have to be present for in the last six months so there has to be a marketing Congress, a strong desire to get rid of the primary and secondary sex characteristics, a strong desire for the primary and secondary sex characteristics of the experience gender desire to be of the other gender desire to be treated, or the conviction that one has the typical feelings and reactions of the other gender. So important to keep in mind and to mention here is that, and we, I think we have all, we all grew up with, with the notion that you have males and females but over the years, this notion has changed and gender is nowadays really, really seen as a spectrum so people can identify as male or female, but it can also be something somewhere in between male or female or outside that binary. And the same for gender incongruence is also can also be seen as a spectrum where people can have mild distress or extreme distress, and really needs medical assistance to relieve this distress, or other options. So, gender science are also not always binary, or, or traditional where it's not, you become a male or female but it's more individualized, where we really focus on what the, the adolescent or what the person needs. So, in that sense in the earlier days when an adolescent would come in, we would really talk about how to have all the possible interventions that were available, and nowadays we have talks with adolescents to talk about the maybe only a breast removal, or only a period of hormonal therapy. Another thing to point out is that adolescence, which an incongruence are really vulnerable to experience psychological distress in this charge we it clearly shows that about 70% in Canada 50% of, of the adolescents in the Netherlands, and show psychological distress in a clinical relevant range on a parent report questionnaire. And where they generally show more internalizing behaviors like depression or anxiety, instead of externalizing behaviors rule breaking rule breaking behaviors or aggression. And so there may be some differences between countries but generally you see that they, they are more vulnerable than the general population. This is the same for suicidality and suicidal ideation. So we recently published a paper where we compared Canada, the Netherlands and United Kingdom and you see that an adolescence with gender incongruence, and definitely show more suicidal thoughts and report more self harm behavior, compared to non referred adolescence or the general population so this is definitely something to keep in mind and discuss with adolescence you see in your practice. Beside psychological distress we also see like a certain conditions more prevalent and one of these conditions is autism spectrum conditions, and is perceived like nine to 10 times more is more prevalent in adolescence with gender incongruence compared to the general population. And it can be complex in in counseling and understanding the gender and gender incongruence for clinicians, and there's a lot of discussion has been a lot of discussion, whether it is, it is an A and autism spectrum conditions are are there, or before or they are the result of gender incongruence or gender incongruence is the result of autism. And we have seen over the years that it can be two separate phenomena, but still in the counseling, and it can be quite complex to counsel people with ASC. And the sexual experiences, and I wanted to point out, and it has long been assumed that people and adolescents and people who struggle with gender incongruence, do not explore their sexuality so they, they were in the early days perceived as asexual, you struggle with gender incongruence, so you don't like your body. So you don't sexually explore. So if you look to the blue bars, and especially in the in the older adolescents you clearly see that they do explore their sexuality, but they do it in a less than the general population the orange bars, but it's, it's, it's, this is important information in the discussion with adolescents, what it says about their gender incongruence and their sexuality, but also what the future effects will be of certain treatment steps on their sexuality and sexuality. So, after having a clear picture on on Jen on the gender incongruence and the broader functioning of the adolescence, and we slowly come to the to the part where we have to make a decision whether an adolescent should start with, and a certain treatments like human suppression and cross sex hormones. The growth during puberty suppression, or other effects of treatment, and to wait the burden and capacity and capacity against the pros and cons of these treatments and have a shared decision together with the adolescent and family, and what they should do with certain treatment So, Dr. Hanama will definitely say something about fertility but but fertility options are increasing and making decision about this is not only about the desire of having a genetic child from your own, but also about whether you can and are strong enough to go through certain procedures. So it's always a shared decision, and we always make it a team decision where we, we, as a team in the gender team make the decision, together with the family, whether it won't should start with puberty suppression or hormonal treatment. I would say in Amsterdam we have a relatively long experience in treating transgender youth and we're quite convinced in doing it but lately over the years we've seen a very, a lot, a lot is going on in our field so there's, as I said, there's a very sharp increase in referrals, and it can be the effect of acceptance. And it also raises the question whether we still see the same kind of adolescence as we did in the earlier day so did the phenomenology change or developmental roots, or made a other kinds of gender identities coming in. We did not see in the earlier days. So I will will discuss this a little bit. In the paper I'm again I noticed one of our PhD students did this study and what she did she compared the all the cohorts we had seen over the years, whether there was a difference between the cohorts and interestingly, for almost all measures we used in this study, we did not see differences in the amount of psychological problem problems demographic background variables, or the amount of gender incongruence so it did the group that is coming in, is not not very different on on these markers, then before, but interestingly, we do see a very interesting change in sex ratio, over the years so in the earlier days we saw a one of one sex ratio where we saw as many boys and girls coming in, but since 2000 and 2013, with the, and at the same time with the increase in referrals, we see more birth assigned girls coming in, compared to birth assigned boys. And we don't have really have an explanation, but it is very important and interesting observation we should find out why this is happening. And another thing at the same time is is a study reported by Lisa Littman, who reported by parent report about a developmental route where she wants to our field that she saw a lot of primarily birth assigned girls, and having a very sudden or rapid onset of gender dysphoria, without a history of gender dysphoria but they are now getting referred to gender identity clinics. Again, we don't have a very clear picture on this group and we don't think this is the reason why there's an increase, but it's important to keep in mind that we still have to do a very proper and a very detailed assessment. So, we don't overlook a certain differences then we saw come in coming in before. So we talked a bit about the shift in identity. So, and now starting to have one or four PhD students and publish the paper about a UK sample, where she showed that most of the adolescents coming in still had a binary identity so they identify this male or female, or as trans male or trans female, but there's also she also identified a group about 10% of adolescents who identified as non binary or age gender. So, that is definitely something we didn't see years before this so that's also something we have to focus on and find out whether there are differences in in how we should counsel the this group and and what their needs are. So, in summary, and I hope I have pointed out that there's a clearly a need to do a proper psychological assessment in transgender youth. And if you do so I would definitely recommend to have a very holistic focus, not only about the gender incongruence but also focus on the general functioning. It's not a static and procedure. It's an ongoing diagnostic process where you take step and you evaluate these steps and find out what the needs are and how it helped the adolescents, and taking these steps. And in our view it's very important to have that multidisciplinary interplay between mental health and medical professionals in counseling, and in assessing and providing information to the adolescents who are getting referred. Thank you. Thank you very much, Thomas, for that excellent presentation. So we have a number of questions in the q amp a box, and I'm going to begin with the first one. So the first question comes from Susan Strad, and basically asking if you have any opinion on whether endocrine disrupting chemicals might have triggered the sharp increase in self identification and referrals, perhaps in addition to increase social societal acceptance. Well, as you may have understand I'm a psychologist so I'm not very into the medical influence on gender incongruence in the development of it. I think with all the commotion about hormonal levels in our food, etc. It's something to take into account. On the other hand, I think we've seen there's a much stronger factor involved nowadays that I think that the factor of social acceptance and recognition for the trans population is a much stronger factor at this point where we see a sharp increase. On the other hand, as I hope I explained clear enough, we also see a bit of change in our population and that's because I think the way we think about gender is changing too. And that's interesting to keep in mind also that it may also be as an influence on the increase. The other thing is, it's very interesting that it's a worldwide increase around the same time period so, and I would say social acceptance is a far stronger factor in this. Thank you, Thomas. So here's a here's a question. This is coming from Dr. William Malone, and he says the Dutch protocol is being used in a blanket fashion. Now for any young person with gender dysphoria, regardless of whether a persistent childhood onset dysphoria or late post pubertal onset usually females with psychiatric comorbidities. Do you have any comments on this. Well, I think that the Dutch protocol is, I know it's the first protocol ever published about how to treat adolescents and in the beginning, and this is also about the population, we historically we've seen a very large group of early onset and trans adolescents coming in with a very strong childhood gender incongruence. And this has changed over the years where we also see adolescents coming in with maybe a bit later onset. On the other, and it's a good question because we really have to keep in mind that the group we are seeing is increasing but it's also slowly changing, but I think there's a lot of discussion about this or feel there's a bit, it's definitely polarized where people would say well you should not treat or, or you should just go on and how you did. And I think it's important that we have a very individual focus and really focus on on how the child has developed and that's why I think it's very important that I also saw a question in the chat about what's the importance of psychological assessment. Does every child need it. In my opinion, for every adolescent you should do a very proper psychological assessment to have a very clear view on their development and understand it. And there's another thing that an adolescent onset is sometimes perceived as a different onset or maybe a less true gender incongruence, and that's definitely not the case because I think around puberty when the puberty sets in, this gives so much other information for adolescence that it should be seen as the same kind of gender incongruence and not necessarily something we should treat differently. Thank you very much. Okay, there are quite a few questions. Here's one from Asa Savick, I apologize if I'm not pronouncing that correctly, who asked, is there an age cut off in which the gender incongruence is more likely to be persistent. Related to this, is there a lower age limit as to when you would consider initiation of pubertal blockers. Yeah, well to be honest I was not very happy with how the slide about childhood came out in my presentation because I think it's a very important message to say that children are still in development, but it's very important to keep in mind that we should take pre pubertal children very serious with their gender incongruence. But on the other hand, we do still see that they are in development and for some the gender incongruence will desist over time and they don't need a medical assistant later. And what we see around the age of 10 to 13 is a very crucial period in this, where puberty sets in for a lot of children, but also social factors change. So you could say that from the perspective of a psychological maturation and the consolidation of gender identity, I would say that when you're around the second phase or the second stage of puberty and a child is psychologically matured with all the social influences, you could say that that could be a cut off to make medical decisions. But to go earlier, the necessity is not there from a medical perspective. And on the other hand, I think you should give the child the time to explore. Thank you, Thomas. There are many, many more questions. I wish we could have more time for you and all the speakers, but thank you so much for your very thoughtful responses and your excellent presentation. Thank you. I'll now turn it over to Dr. Merrick. Thank you. Thank you very much, Thomas. Now we are going to move to the next speaker. I'm delighted to introduce Sabine Hennema. She's a pediatric endocrinologist at the Amsterdam University Medical Center, where she works at the Center of Expertise on Atypical Sex and Gender Development. Her clinical work and research focuses on transgender care and DSDA, and she's co-author of the Endocrine Society Guidelines for Endocrine Treatment of Gender Dysphoria in Congregate Persons. Dr. Hennema is going to present on hormonal management of gender dysphoria in adolescents. Thank you for the introduction. And I'd like to thank the Endocrine Society for inviting me to talk to you about hormonal management of gender dysphoria in adolescence. These are my disclosures. And in this talk, I'm going to talk about hormonal management of gender dysphoria in adolescents. I'd like to briefly outline the current recommendations for endocrine treatment, discuss fertility counselling, show you some data on the efficacy of treatment both for puberty suppression and for oestrogen and testosterone treatment, and discuss the safety. So, first of all, current recommendations. I'll discuss the treatment as outlined in the Endocrine Society guideline. And first of all, I'd like to stress that no endocrine treatment is recommended for prepubertal children. But once adolescents reach puberty and have a diagnosis of gender incongruence, wish treatment, have no contraindications and give informed consent for the treatment, then puberty suppression can be started as the first step of gender affirming treatment. And junior age analogues are the first choice medication. But if not available or not affordable, other medication can be used to suppress endogenous testosterone production, such as progestin or antiandrogens. And as the next stage of gender incongruence persists and adolescents have reached an age where they can give informed consent for this treatment that has partially irreversible effects, then pubertal induction can be started. And for trans girls, this is done using 70 beta estradiol. A gradually increasing dose schedule is used, just as in other adolescents with hypergonadism. And in those who've already gone through endogenous puberty and have finished growth, the dose can be increased more rapidly. And for trans boys, testosterone is used again, gradually increasing the dose. So some concerns have been raised about this treatment. For example, in this letter to the editor in response to the guideline saying, how can a child, adolescent or even parent provide genuine consent to such a treatment? How can the physician ethically administer gender affirming therapy, knowing that a significant number of patients will be irreversibly harmed? And in some countries, cases have been brought to court to implement legal constraints. And the concerns that have been raised are the low diagnostic certainty, the ability of adolescents to give informed consent for the treatment and the risk of sterility, sexual dysfunction and adverse health outcomes such as cardiovascular disease. And in this presentation, I will try to address these points. I won't go into the low diagnostic certainty because the diagnostic assessment is discussed by Thomas James, but I will go into health outcomes such as cardiovascular disease. And I'd like to start with discussing the point of fertility. So the endocrine society guideline recommends that all individuals who seek gender affirming medical treatment are counseled about fertility preservation prior to the start of treatment. And this is true for both adolescents and adults. In practice, several studies have found that many transgender adolescents and young adults desire to have children sometime in their life. However, a relatively low uptake of fertility preservation among adolescents has been reported, although quite variable, ranging from zero to sixty three percent. And trans girls more often make use of fertility preservation than trans boys. And there's differences between countries with several studies from the United States and Canada reporting low uptake, below 10 percent, whereas we found in a Dutch cohort of trans girls at about a third attempted fertility preservation. And a recent study from Australia reported higher intake, higher uptake, again, of sixty three percent. And barriers that have been described are the lack of counselling or incomplete counselling received by the adolescents. The need to stop or delay treatment for fertility preservation. The invasiveness and psychological impact of the actual procedures, costs and the availability of options. And I think these last two may explain some of the variation between clinics and countries, with some countries reimbursing costs of fertility preservation and also some clinics offering experimental options, for example, to stick to preservation for early pubertal trans girls, whereas other clinics do not offer this option. And I think these first two points, the counselling and timely counselling, so that adolescents actually have time to consider fertility preservation, are something that every clinician who sees adolescents for treatment can try to improve. So we should try to implement fertility counselling in our in our clinics. And what needs to be discussed? Well, first of all, adolescents need to have an understanding of reproductive biology. Then they need to be informed about the possible impact of treatment on fertility and about fertility preservation options, the benefits and risks of the procedures and the alternate pathways to parenting. So that they can make an informed decision about fertility preservation and the treatment. Then once they start puberty suppression, what do we try to achieve? Well, the treatment aims to prevent further development of secondary sex characteristics and thereby prevent worsening of dysphoria. In addition, the physical appearance will remain more in accordance with the affirmed gender and the treatment may reduce the need for future surgery or result in less in a need for less invasive surgery. And lastly, it provides time for the adolescent to reflect if they wish to pursue further treatment. So I just showed some of the data looking at each of these points. So first of all, the prevention of development of secondary sex characteristics. This is one study looking at hundred sixteen adolescents treated with Trevelin. And they found adequate suppression of gonadotropins and sex steroids. Menstrual bleeding stopped in all trans boys. And there was a decrease of testicular volume in trans girls, as shown in this graph, comparing testicular volume at the start of treatment and after one year of general analogue treatment. So the treatment is effective. A Belgian group has studied a different approach to suppress endogenous sex steroids, using the progestin lumestranol in late pubertal trans boys. That's 10SHB4 or B5, because for this group, deuterated analogues were not reimbursed. And they were treated with lumestrol five milligrams per day. And this was less effective in suppressing menstrual bleeding than deuterated analogues, with about half still experiencing bleeding in the first six months. But this did decrease in the next six months. So the Belgian group also looked at the use of ciproterone acetate to treat late pubertal trans girls. That is 10SHB4 or B5. And they were treated with 50 milligrams per day. And this did result in a decreased need to shave in more than half. And some reported decreased spontaneous erections, although this outcome was not systematically collected for this study. And a third actually had some breast development up to 10SHB2 or B3. So this treatment was effective. But I'd like to point out that there's been a warning because of increased risk of meningioma associated with this medication, which is cumulative dose dependent. And in our clinic in Amsterdam, where adult trans women used to be treated with ciproterone acetate, we no longer use this and now offer deuterated analogue treatment instead to suppress testosterone production. So then do we improve psychological outcome with puberty suppression? And it's good to point out that the puberty suppression is given alongside mental health support. So several studies have looked at psychological outcomes and have found less parent reported behavioural and emotional problems after treatment. Although a recent study from the UK with a relatively small sample size did not find a change. Studies have found less self-reported problems, better global functioning, less depression, less suicidality, better peer relations, but no improvement of body image. And this is not so surprising because although further pubertal progression is prevented, the body doesn't actually change towards the firm gender in some studies. Outcomes have been comparable to peers, but in others, more problems persisted compared to adolescents from the general population. Then another aim was to maintain the body that was more similar or more in congruence with the gender and prevent surgeries later on. And this is a study that looked at this in trans men comparing a group who started puberty suppression in early puberty, so tender stage B2 or B3, late puberty, tender stage B4 or B5, or a control group that started treatment in adulthood. And if you first of all look at breast size, this was smaller in the group who started puberty suppression in early puberty, with the vast majority having Cup A or AA compared to the other groups. The group that started in late puberty still had smaller breast size than those who started in adulthood. And this did result in reduced need for mastectomy, with only about half of the group who started in early puberty undergoing mastectomy, compared to nearly all and all who started in late puberty and adulthood. And those who did need a mastectomy could make use of a less invasive procedure with a peri-regular semi-circular resection, whereas those who started in late puberty, especially those who started in adulthood, more often needed a more invasive procedure with an infra-memory fold approach. Also, the weight of the breast tissue resected was smaller in those who started in early puberty versus those in late puberty. And again, they still had a lower weight than the ones who started treatment in adulthood. And looking at trans women, here you can see that the group who started puberty suppression in early puberty had a smaller penile length than the group who started in late puberty, who still had smaller length compared to the ones who started in adulthood. For trans women, this actually means that vaginoplasty will more often require a more invasive procedure, because the penis inversion technique that's generally used in most adults cannot be used if there's not sufficient penile and scrotal skin because of early suppression of puberty. So in this group who started early, an intestinal vaginoplasty was more often required than in the other groups. So this is important to counsel adolescents about before they start the treatment so that they know what impact the treatment will have on their options for later surgery. Then lastly, the aim of the puberty suppression was also to provide more time to consider further treatment wishes. So if we look at the subsequent treatment that adolescents undergo, then the vast majority who start puberty suppression do go on to start gender-affirming hormone therapy. And in this cohort, only 3.5% no longer wished to undergo gender-affirming treatment after they stopped general analogues. And this is quite similar to findings from several other studies. However, adolescents do indicate that they did find the period on general analogue treatment helpful. For example, this adolescent who decided to stop treatment said, after using general analogues for the first time, I could feel who I was without the female hormones, and this gave me peace of mind to think about my future. So adolescents do make use of this period to explore their further treatment wishes. Then if we look at the data concerning gender-affirming hormone treatment. So this aims to induce sex characteristics congruent with the affirmed gender and thereby decrease body dissatisfaction and improve well-being. So this is looking at breast development in trans girls on estrogen treatment. And you can see that tenor breast stage gradually increases over the first three years of treatment. And after three years, the median is tenor breast stage five. And of course, this doesn't give any information about breast volume, which some may still find unsatisfactory despite having reached tenor breast stage five. Trans boys who are treated with testosterone, an important change is the breaking of the voice. And this generally takes place quite quickly after the start of testosterone treatment. Most have experienced some change in their voice after three months of testosterone. And the rate at which this takes place is dependent on the rate at which the dose is increased. Facial hair takes a bit longer to develop, but most trans boys have experienced some increase in facial hair after six months of treatment. So if we look at body shape, you can see that when comparing waist to hip ratio between start of junior age analogue treatment, start of gender affirming hormones and age 22 years, you can see that changes occur. This is the reference for cisgender men and cisgender women, so the women have a lower waist to hip ratio, meaning they have wider hips. And you can see that in trans women, the waist to hip ratio decreases during junior age analogue treatment and then a further decrease during oestrogen treatment towards the reference of cisgender women. Whereas in trans men, the opposite occurs, that during testosterone treatment, the waist to hip ratio increases and becomes more similar to that in cisgender men. And the trans men who start puberty suppression in early puberty end up with a higher waist to hip ratio, indicating that if you prevent the development of wider hips in puberty, this results in a lasting effect that's still visible at the age of 22 years. So we can induce sex characteristics with pubertal induction that are congruent to gender identity. Thus, this also results in an improvement of psychological outcomes. Several studies have looked at this. Some adolescents or young adults had already received gender-affirming surgery as well. And with this treatment, less parent-reported emotional and behavioural problems were seen, less self-reported problems, better global functioning and less depression. And this treatment also resulted in improvement of body image. And in some studies, the outcome was actually comparable to PIS. For example, in a Dutch and German study, whereas in others, more problems were still present in the transgender adolescents compared to the general population. For example, a Finnish study. So the treatment is effective in inducing sex characteristics in line with the affirmed gender and improving psychological well-being, but what about the safety? Well, first of all, adverse effect of puberty suppression. Mild headaches and hot flushes are fairly common, seen about a quarter of adolescents, and moderate or severe headaches and hot flushes are less common. Mild fatigue has been reported, as well as mood swings, weight gain or sleep problems. There's been a steroid abscess reported, but this seems rare, as well as hypertension. And no renal or liver disease was found in studies. And looking at adverse effects of gender-affirming hormone treatment, acne is a very common side effect of testosterone treatment, found in up to 60 percent. And breast tenderness was most common with oestrogen treatment. Other adverse effects that have been reported are fatigue and hunger, emotionality, especially with oestrogen treatment, but no renal or liver disease, no change in HbA1c. And actual adverse events are rare, but there have been two case reports of venous thromboembolism in two 17-year-old trans boys. They did have other risk factors for venous thromboembolism. One was obese and the other had a history of smoking and used ethinyl isradiol in addition to testosterone. So actual adverse events are rare, but what about risk factors for future adverse outcomes, for example, cardiovascular disease? So this is a large study from Amsterdam looking at 121 trans men and 71 trans women, and they found an increased prevalence of obesity. These are data at age 15 years, which was the average age at which generate analogue treatment was started. And the trans men shown in blue already had a higher prevalence of obesity compared to cisgender men, cisgender women and transgender women at age 15, especially at age 22 years. Both the trans women and trans men had a higher prevalence of obesity. And this may be to do with lifestyle factors. So I think it's important that during the care for adolescents, weight is monitored and adolescents are advised about lifestyle factors and how they can maintain a healthy weight. So the same study from Amsterdam looked at changes in blood pressure, comparing data at the start of generate analogue treatment, start of gender affirming hormones at age 22 years. And they did find changes during treatment, for example, a rise of systolic blood pressure in trans men and a rise of diastolic blood pressure in both transgender groups. But if you compare outcome at age 22 years, it's very similar in the transgender population compared to the cisgender population. So that's reassuring. The same study also looked at lipids and again found changes over time. But at age 22 years, values of the various lipids were similar to those in cisgender peers or actually more favourable, such as a lower LDL cholesterol in trans women and a higher HDL cholesterol. So this is reassuring. Then looking at the hematocrit, it's a well-known effect of testosterone that the hematocrit increases. And you can see in these adolescents after the start of testosterone during the first year, there is an increase and various studies have found an increase above the normal range in zero to 10 percent. So this is important to monitor because an increased hematocrit is a risk factor for adverse cardiovascular events. And if it's persistently high, then one can adjust treatment. Then another concern is bone health, especially the effect of gene or age analogue treatments. And indeed, you can see a decline of bone mineral parent density that's caused over two years in treatment in both early and late pubertal trans boys and early and late pubertal trans girls. And it's important to notice that the trans women already start lower and this has been found in adults as well. So if we compare the outcomes of bone mineral density using gene or age analogue treatment to those found with lunastrol and tiproterone acetate, then it's notable that lunastrol does actually result in stable BMD Z scores at the whole body, lumbar spine and femoral neck. So this may be an advantage over gene or age analogue treatment. Tiproterone, on the other hand, does result in a decrease of Z scores, just like gene or age analogues. So then once gender affirming hormone is started, there's an increase again of the Z scores in both the early and late pubertal trans boys and trans girls at the lumbar spine. At the femoral neck, however, the late pubertal trans girls show only a very small change of the Z score. And if we look at data at age 22 years, again, looking at bone mineral priority density Z scores, you can see again that the trans men there's a decrease during gene or age analogue treatment, but a catch up to a Z score of around zero at age 22 years. Whereas in the trans women, there's a decrease during gene or age analogue treatment and they already started rather low. And then there's relatively little change during oestrogen treatment. And this may partly be to do with lifestyle factors, because in adult trans women prior to the start of any treatment, low bone mineral density has also been found. And this is possibly related to, for example, being less physically active. And we know that transgender adolescents have a lower calcium intake than recommended, often have vitamin D deficiency, exercise less than peers and smoke and drink alcohol more often than peers. So these are important factors to address during the follow up of these adolescents. So to conclude, puberty suppression and pubertal reduction are effective, and most studies have shown improved psychological functioning and well-being with the treatment. And just to come back to some of the concerns that have been raised about the treatment, fertility is a very important issue to discuss and counseling should be offered to all adolescents. Discussing the possible impact of the treatment on fertility and options for fertility preservation. Then the other concern was about adverse health outcomes, and I think the short term safety data are reassuring with very few actual adverse events reported. But there are still questions about the long term safety. And again, the data on blood pressure and lipid profile are reassuring with regard to the risk of risk factors for cardiovascular adverse outcomes. But we need to await data on the actual health of these adults as they grow older. And in general, there's still limited data available in this area. So this is why we continue to carefully monitor all adolescents who use this treatment and collect further outcome data. And as I discussed in the previous slide, I think it's very important to address lifestyle factors and counsel adolescents on this so that this because this will help to optimise health outcomes for these adolescents. So these are some key references. And I'd just like to thank my colleagues from the gender teams in Amsterdam and Leiden and thank you for your attention. Thank you, Sabine. This was a great talk and probably many of the questions have been already answered through your talk. There is a question by Thomas Wilson, actually two questions for him. He's asking, which standards do you use when you evaluate mineral density in transgenders? So for the study that I showed you, we calculated scores based on data from NHANES. OK, but do you use the same gender or the gender? I see what you mean. So for this study, we used the reference data from the sex assigned at birth, which at baseline seems seems reasonable because there's not been any endocrine treatment. And then for follow up, we decided to use the same reference because if you change halfway through, then it would be more difficult to compare that scores. With more prolonged hormone treatment, one could argue that you could switch to using references from the affirmed gender. OK, the same Dr. Thomas Wilson is asking whether you have any information on long term effect of testosterone on ovarian function in a trans woman who wishes fertility after GnRH therapy. So I've not looked at this. We've not done any studies ourselves, but there is some literature on this. There's still questions on this topic as well. So we know that some people have stopped testosterone treatment and ovarian function has resumed. And I think there's still limited data. So it's still a topic that deserves further study. Yeah, this is a question of myself. I have two questions. In a trans female, in a trans girl who has a history, family history of breast cancer or of thrombophilia, do you do any screening before doing the estradiol treatment? So we have seen adolescents, for example, with a positive family history for thrombosis. And we generally do refer them for consultation with a paediatric haematologist to advise on the need for investigations. And sometimes they come back and there's not been a particular cause identified, but then the risk will still be increased with a positive family history. So I think, again, it's it's important to counsel adolescents on the on the risk of the of the treatment in combination with with estrogens. And one may prefer to start transdermal estradiol rather than oral estradiol. There's no strong evidence, but that's something that you could consider. And I already saw a question about the use of ethinyl estradiol as well. So I would definitely avoid that in all. We don't use it at all, but because of the increased risk of thromboembolism. So that's something that would well, especially with a positive family history, I don't think you would want to use advice on smoking, etc. Other risk factors that would increase the risk of thromboembolism. Do you have any comment on the pending legal prohibition of the use of gonadotropin analogs for the treatment of gender dysphoria adolescents? This was passed recently in December and there were in the High Court of the UK and probably in the States. What I'm seeing a question from Victor Pope from Alabama. So maybe in other states in the United States, it's also a provision of the use of these analogs for the treatment of gender dysphoria. What would you advise them? What is your thinking? Maybe not supervise. Yes. So, of course, I've shown in the presentation that we are aware of the criticism that that is there. But I think I've tried to show you the data that I think show the benefit of the treatment. And of course, there are unknowns and the things that we really need to need more research for. But I think with the data that we have at the moment and the psychological improvement and the safety data that we should be offering this treatment to adolescents. And of course, if there's legal barriers, I think this will harm many adolescents. And in the UK, it's been decided that a court should be involved to see if the adolescent can give consent, whether treatment is appropriate or not. But I think, as Thomas Staines also said, the mental health person from the from the multidisciplinary team already really tries to provide a thorough assessment and counseling and weigh all the pros and cons for the treatment together with the family. And I think the team is then better able to assess if the adolescent has understood and appropriately weighed all these factors rather than a person from a court. Yeah, there is another question. This is a practical question of Dr. Nagan Betilai, which is asking about the rash with testosterone CPN injections. And she has premedicated this patient with Benadryl, which did not help. And the patient does not want to use gel. Do you have any recommendation in the change of testosterone pathway administration? But I guess if you think this person is allergic to the testosterone, then perhaps testosterone on the can of it could be an option. I don't know the difference. Different testosterone products are not available everywhere. So I don't know exactly what's available where you practice, but perhaps that could be an option. Thank you, Sabine, for your excellent talk and probably the questions you may also answer some of them online and there are a bunch of questions to come. So I was very, very much interested in your talk, which almost answer most of the questions that were raised. Thank you. Thank you. And maybe some of the two more talks on transgender fertility and laboratory assessment. So some questions may be answered in those talks as well. Thanks. Thank you, Sabine. That was wonderful. So it's now my pleasure to introduce Dr. Vintage Preacher. Dr. Tang Preacher is professor of medicine at Emory University and currently serves as founder and director of Emory's Transgender Clinic. Then has made major contributions to transgender health through NIH and other federally funded research, as well as through significant advocacy and educational efforts. Dr. Tang Preacher has served as co-author of the Endocrine Society's Clinical Practice Guidelines, both the original version published in 2009 and then the most recent version published in 2017. He's also chair of the Hormone Chapter for the Standards of Care 8 that is hopefully soon to be released on behalf of the World Professional Association for Transgender Health, also known as WPATH. And Dr. Tang Preacher has also recently completed his term as president of WPATH. The title of Dr. Tang Preacher's presentation is Transition of Care for Transgender Youth. Vint, please. Thank you very much for that introduction and thank you to the Endocrine Society for allowing me to participate in this symposium. The title of my lecture is Transition of Care for Transgender Youth. And I don't have any disclosures. I do disclose that I'm an adult endocrinologist, not a pediatric endocrinologist. And this is my agenda. So five agenda points. We're going to cover the steps of a successful transition from a pediatric to adult practice. We'll discuss the differences in transgender care between youth and adults. We'll talk about the unique health care needs for transgender youth. And we'll cover a proposed timeline for transition of transgender youth from pediatric to adult practice. And we'll talk about some resources that currently are available to help you successfully transition transgender youth to adult practices. So I'm going to start off with a case. And this is a relatively new area for me. And then after the invitation to speak at this conference, I realized this is a very important topic for all of us taking care of youth and adult patients with transgender identity. And so this is a real case that I saw recently. This is a 16-year-old transgender girl who initially presented to her pediatric endocrinologist for initiation of gender-affirming hormones. She's had feelings of gender dysphoria since age five. She was evaluated by mental health, who confirms the diagnosis of gender dysphoria and supports gender-affirming hormone therapy as the next step. She was started on estradiol and spironolactone, which was increased to a final dose of estradiol, two milligrams twice a day, and spironolactone, 100 milligrams twice a day. And her estradiol levels ranged between 100 to 160 picograms per mL in the target level of the endocrine society recommendations. And the testosterone levels have ranged between 20 to 39 nanograms per mL, also in the range recommended by the endocrine society guidelines. And she's quite happy with this regimen. She's done very well, and she graduated from high school and has been going to a community college. She still lives at home with her parents. On the patient's 19th birthday, this is three years after starting gender-affirming hormone therapy, she reveals that she's very interested in having gender-affirming genital surgery. Parents reveal that she doesn't know her own doses of medication or know how to access the health system. They are concerned that she will not do well after surgery with the post-operative care. And they also have concerns with the timing of surgery. So I present this case because it illustrates some of the issues that we're going to talk about today. And the question I have for myself is, what could have been done better to transition this patient to an adult care model? Health care transition has been something that's been very important, and several societies have published on this. This has been published by the American Academy of Pediatrics, American Academy of Family Physicians, American College of Visions. They have published several consensus statements on health care transition for youth to adults. And the transition, the definition of this is the process of moving a child to an adult care model with or without transfer to a new clinician. This is a cartoon that I adapted from Garvey and just illustrates what a successful transition should look like. In childhood, obviously, the parent makes a lot of the health care decisions and takes on the responsibility of many of the health care needs of a child. And during early adolescence and teen years, the adult is still involved in the medical decision making, but starting to break off a little bit. And hopefully by adulthood, the child becomes an adult and the parent has less of a medical decision making role. Transition planning is very low among U.S. youth, and I was surprised to see this as an adult provider, but it's important to note that we could do better. And this is a survey from 2016 of 20,000 youth ages 12 to 17 and their adults. And they simply asked parents if transition planning occurred based on health care provider discussion, health care provider actively working with the youth to gain self-care skills, and the youth had time alone with the health care provider. And surprisingly, only 17% of youth who had special health care needs had transition planning, and that's not much better than youth who don't have special care health needs. So we need to do much better in transitioning care from youth to adults. What about specifically endocrine patients? And this is a study looking at adult endocrinologists caring for people with type 1 diabetes. And they asked several different questions, how important certain aspects of transition planning were important and how often it happened. And you can see here, I just selected a few, many endocrinologists, over 70% felt that a patient care summary and review of pediatric record was very important or important. But very few, very often this did not happen. Only 10% of the time patient care summary record was available, or only about 30% of the time that the review of pediatric record occurred. Parent at a first adult visit happened about half the time, and many people thought that was important. Unfortunately, not many people have transition programs for children who become adults with type 1 diabetes. And why is this so important? So there's been some studies looking at transitioning of youth and looking at health outcomes. And this is a systematic review of nearly 4,000 articles representing 43 studies. And transition planning resulted in positive outcomes in more than half the studies in areas of population health, consumer experience, and service utilization. There are several studies focused in endocrinology, including improvement in A1C, reduction of hypoglycemic episodes, DKA admission, self-care, and satisfaction. So what are the barriers to transition care? And this all makes sense. We should do a better job with transitioning youth to adults. And I've listed just a few barriers. There's communication gaps, training limitations. We don't really get this training in our individual programs. There's care delivery, care coordination, support gaps, lack of patient knowledge and engagement, and lack of comfort with adult care. I want to focus now specifically on the transgender population and what are some of the youth to adult transition concerns. I've listed a few here. There could be coexisting psychosocial concerns. There could be lack of access to knowledgeable health providers. There could be health system barriers. There could be financial issues, such as insurance issues and employment. And there could be gaps in prescription coverage. Some medications may be covered in youth and not in adults. And this is from a nice review from Dr. Jessica Abramowitz, published a few years ago. I wanted to spend a couple minutes here discussing the differences that we should all be aware of between youth and adult transgender care. And so in terms of the diagnosis, I think there is a big difference here. In youth, the diagnosis of gender dysphoria needs to be made by mental health providers who have special training. And they need to be under the care of a multidisciplinary team, especially youth under the age of 16. In adults, the situation is different. Medical health providers and or physicians who are comfortable with making a diagnosis of gender dysphoria can make the diagnosis. And the hormone-prescribing physician can be the same person. They could make the diagnosis and provide the hormone therapy. There are also differences in the health care team. In youth, the team is much larger. There's a pediatrician, mental health provider, and those are both required to get started on gender-affirming hormone therapy. There's an endocrinologist and or a hormone-prescribing clinician, also required to be on hormone therapy. Usually involved is a reproductive health specialist and a gender-affirming surgeon later in adolescence. In adults, the care team is a little smaller. There is an endocrinologist and or hormone-prescribing clinician, and that's required to get started on hormone therapy. But many other providers may be optional or the person doesn't have these providers in place, such as the primary care physician, reproductive health specialist, or gender-affirming surgeon. Now, there are differences in hormone therapy, titration, initiation. And I've seen this myself in my practices when getting patients from transitioning from pediatrics. In terms of youth under age 18, many youth are started on GNH agonists to halt puberty. And at the appropriate time, transfeminine or transmasculine therapies are initiated at lower doses and titrated up. In the United States, we don't have GNH blockers readily available for adults. And so we're typically using other androgen-lowering medications. And I think that's a key difference in youth-to-adult care. We have different hormone regimens. Not quite different, but you can see the dosages are much higher compared to what's given in youth, although the target levels are about the same. In terms of monitoring therapy, there are differences in youth and adults. In youth, there is concern about growth and bone health. And you can see the recommendations are to measure weight, height, blood pressure, and tanner stages every three to six months. Because of the emphasis on skeletal health, the Endocrine Society recommends 25-hydroxy-VIMD every six to 12 months. And you can see many of the other measures here. I just want to point out that the prolactin is still being measured, but that may not apply to all regimens, especially spironolactone-based regimens. In youth, the bone density is measured every one to two years. And bone age is often a focus in youth, especially those who do not reach peak bone mass. In adults, the care is a little different. Clinical visits are every three months in the first year and only once or twice a year. In transmasculine, total testosterone, hematocrit, and hemoglobin are measured. In transfeminine, total testosterone, estradiol, and potassium for those on spironolactone. So the testing is a little streamlined. Cancer is a topic that's brought up later in life. And bone density for those people who have risk for hypogonadism. In the next three, four minutes, I want to end my talk with a proposed transition timeline. And I adapted this from the American Academy of Pediatrics. I like the steps. There are six steps in successful transition. Step one is discussing a transition policy. Step two is tracking the progress. Step three is assessing the skills. And step four is developing the plan, including the medical health summary. And step five, hopefully the transition has occurred. You're transferring the patient to the adult care and integrating the patient into adult practice. And then later, step six is confirming the transfer is complete. We'll go through these steps briefly. So in step one, specifically for transition of trans youth, I think it's important to have a consistent practice-wide policy or planned approach for transitioning youth. I think this could be facilitated by developing a policy statement with input from youth and families that describes the practice's approach to transition, educating our staff and positions in the policy, and posting and sharing this policy with our family. We created a toolkit. Dr. Jessica Bromowitz and I posted some tools and I'll share a couple of these in my talk at the Endocrine Society website. And you can also go to gottransition.org. Step two is tracking the progress and developing a registry who are starting this progress of transition. And this occurs from age 14 to 16. And step three is getting ready. And this is checking that the youth have the skills to transition. And we developed some tools that question trans youth on their social situation, how they access health care, how they take care of themselves, their medical and mental health history and medications. This is a sneak preview of some of the forms we have created. I think these are very nice that providers can hand out to patients and just be a discussion point on whether or not the youth is ready to transition. Step four is actually starting the transition process. And it's introducing the process of health care transition and increasing self-management and ultimately transferring to adult care. We think this should be initiated around age 16 when most youth have achieved their adult dosing. And patients and families should continue to participate in this ongoing self-management education throughout the teenage years. We should discuss the expectations of gender-affirming hormone therapy, especially through the rest of childhood, and the timing of future gender-affirming surgeries if desired. And we should individualize transition skills according to the needs of the patients, help patients understand what their role is in the transition, and work with the patient to develop and review health care summaries and emergency care plan. Step five is the final transfer. And so we're planning to transfer to adult care, work with the patient and family to clearly identify adult providers who are competent in providing trans-affirming care. I think this is so very important. I think that's where our care is somewhat fragmented. And I think we really have to help our patients identify the providers who will assume the care from the pediatric teams. We've got to exchange information to the adult teams and send the transition package of necessary medical records. And there are some tools on the Endocrine Society website. This is an example of a transfer record, talking about the name, preferred names, whether or not they were on blockers during youth, different hormone dosages. So please check those out. Step six is completing the transition, continuing to provide medical advice and supporting the young adult patient until transition is complete. And step two is just putting measures in place in the pediatric practice to make sure the loop is closed and the transitioning patient is fully established in adult care. Back to our case. Our patient was provided handouts from the Endocrine Society that focused on knowledge of medications, dosages, potential adverse events that require immediate medical attention, how to access healthcare providers, and materials on what to expect before and after surgery. She's still working on this now. Patient's continuing to practice on how to access healthcare system, especially like getting appointments, getting refills, being able to come alone to her appointments. And the family is right now researching surgical options. And so I think she's come a long way, and hopefully at the right time she'll be able to have her gender-affirming surgery. I just want to highlight some of the resources that are available. I mentioned the Endocrine Society has a set of tools, and I just mentioned a few of them in my talk, but please check out all the tools that are available under transition in transgender and gender-diverse people. You can check out the WPATH website for guidelines. The Endocrine Society guidelines, of course, published in 2017, and the review article on youth-to-adult transition by Dr. Jessica Abramowitz. Thank you very much for your attention. Vin, thank you so much for this excellent presentation. And I think this toolkit is such a great resource, and thank you so much to you and colleagues for making that available through the Endocrine Society website. There are a number of questions here, and I will start with one here from Dr. Madhu Misra. Basically, she is asking... Let me find it here. Yes. How does the diagnosis of autism in transgender individuals influence the age of transition or the transition process? This may be a better question for Dr. Steensman, but I'll try to do my best. Most of the time, in adult practice, most people are able to articulate their gender identity. And I would say a large majority are able to do that, but people with autism might require special attention, depending on how severe the autism is. If they're able to clearly articulate their gender identity, I don't know if it really impacts the hormonal care, and so you proceed as usual. However, if there are some concerns in making the diagnosis, you might want to get a mental health specialist or someone that specializes in autism to help you follow along with that patient. Thank you. One of the challenges that I think many of us at work on the pediatric adolescent side is that if we're able to provide an interdisciplinary model and really implement a family-centered model of care, it's sometimes very difficult, even following the guidelines that you suggested, to really transition these patients when they know that they're going to be having less of that sort of wraparound model of care. And that certainly is a challenge. I noticed in one of the slides that you said that that transition isn't necessarily before 18 and then 18 and over, but perhaps targeting somewhere between 18 and 21. Can you comment on that? What if you were, let's say, as an adult provider, asked to see an individual who is 19, let's say, in that range, but who would really seem to benefit from a wraparound model of care, family-centered care? Would you feel that you would rather direct them to the more adolescent side, even given their chronological age, or how would you approach that? Well, that's a great question because I just had a patient this week. She's 19, and she still hadn't adopted the adult care model yet. And we're just still working with her to, you know, I mean, with the COVID precaution, that's actually forced her to adopt the care model because her mom could only be in the waiting room. But we're trying to work with her to understand how to access health care, what questions are appropriate to ask during the visit. It's a challenge, I think. I mean, many of the parents are very supportive, and they want to, you know, make sure the care is appropriate. And I think that you probably see a lot of those parents in your practice. They're always hovering, but we're not used to that in adult care. So we still have to work with a lot of these younger, they're not adolescents anymore, younger adults in our clinics just to get them moving towards the adult care model. Thank you, Ben. So this is a question that came from one of the earlier presentations. So I'd like to ask it because it hasn't really been addressed. And I think it in some part pertains to the evolving terminology that we use in our field and some of the challenges with the implication of certain words. And by that, I'm referring to the fact that the word transsexual is not typically used anymore. It's been replaced by transgender or gender diverse or perhaps even gender incongruence as umbrella terms. But the question that was asked was, and I think this might reflect in part on prior use of the word transsexual and when hearing a word that ends in sexual, thinking about sexual orientation. So the question is, is homosexuality part of the transgender syndrome? I saw that question earlier and I didn't know how to answer that because it's a different, like you said, it's a totally different dimension. I mean, gender identity is your gender and how you express yourself and who you believe you are. And I think if people use this term, sexual orientation is who you want to be with. So it's, I mean, that's a hard question to answer. I don't know. The question is in regards to two different, two totally different questions. So I just, I would say no. The short answer is no. I appreciate that. And then I think the only thing that perhaps I could add to that is just to remind everyone that a person's gender identity doesn't predict their sexual orientation and a person of any gender identity can have any sexual orientation. And you made it very clear that these are different dimensions to the human experience. There are a number of comments here and I think this is a great session. This is from Josh Safford. This was clearly helpful to many as evidenced by the large number of questions. I would say also by the large number of attendees. At the peak we had, I wrote this down, 668. So I think quite exciting. And I think it's certainly a reflection of being able to have this virtual option and how wonderful. So this does conclude our session. On behalf of Dr. Merrick, if we can have Dr. Merrick. We can have Dr. Merrick. On behalf of Dr. Merrick, I would like to thank all the speakers for their excellent presentations. I would like to thank again, Dr. Merrick and the Annual Leading Steering Committee for putting this on the program. And I would like to thank all of the attendees. I'm always sorry that we didn't have more time to get together and hopefully. Thank you, Stephen. Thank you, Stephen. This has been a great session and the number of attendees have been awesome. Unbelievable. So thanks to all. And we hope to have more of this. And we invite you to follow up the rest of the program. Thank you so much. Goodbye. Thank you. Just remind you that there are many wonderful sessions coming up and we hope you enjoy the rest of your week. Thank you.

transgender care

comprehensive assessment

hormonal management

transgender youth

psychosocial assessment

puberty suppression

hormone therapy

fertility preservation counseling

transition of care

healthcare needs

case study

transition planning