Gender Management Service (GeMS) Clinic
The Gender Management Service (GeMS) Clinic at Children's Hospital Boston is a new multidisciplinary clinic that treats the medical and psychosocial issues of children, adolescents and young adults with disorders of sex development (DSD) or with gender identity disorder (GID). The team includes urologists, endocrinologists, geneticists, psychologists, social workers, and nurses.
Many of our DSD patients are born with anatomy that may make it difficult to determine their sex and that may interfere with their urologic and future sexual and reproductive functions. The medical team works closely with families throughout the evaluation, decision-making and treatment process, which often entails long-term follow up.
The GID patients seen at the GeMS clinic have no known genetic, anatomic, or hormonal abnormality, yet they identify as the opposite sex. All of these patients have been previously screened by psychotherapists skilled in evaluation of gender identity. Following an established international research protocol, patients undergo a rigorous and repeated series of psychological and medical tests at Children's in order to assess whether they are transgendered, as evidenced by persistent clinical symptoms that interfere with their psychosocial function and put them at serious risk for self-harm. Carefully selected patients may be eligible for reversible medical intervention in order to suppress production of estrogen or testosterone, but treatment begins only after these patients have entered puberty. This reversible treatment allows patients time to reach an age when they can decide, with their families, whether to discontinue pubertal suppression and resume their puberty or to continue with medical intervention through cross-sex hormone therapy.
Frequently Asked Questions
What are Disorders of Sex Development (DSD)?
Disorders of Sex Development (DSD), also known as Intersex, involve patients who are born with anatomy that may make it difficult to determine their sex and that may interfere with their urologic and future sexual and reproductive functions. DSD typically includes genitourinary or hormonal disorders.
What are some examples of DSD?
Examples of DSD include:
- ambiguous genitalia
- androgen insensitivity
- congenital adrenal hyperplasia
- hypospadias and epispadias
- Turner Syndrome
- vaginal agenesis and MRKH
- Klinefelter Syndrome
What causes DSD?
Some disorders are genetic (chromosome variations), and some are present at birth (congenital) but not genetic. Sometimes the cause is unknown.
What is the treatment for DSD?
DSDs involve conditions that are quite varied, and the treatments are likewise quite varied depending on the complexity of the disorder. Treatments may include medication, surgery, and emotional/psychological support.
What does it mean to be transgendered?
Transgendered patients have a gender identity that differs from their anatomic sex. Many young children play dress up in the clothing of the opposite sex, and some children experience gender dysphoria, but the majority of these children are not transgendered. Only a very small percentage of children consistently and persistently reject their genetic sex into adolescence and beyond. Transgenderism, whose cause is unknown, is extremely rare.
Gender identity should not be confused with sexual orientation. Gender identity refers to one's sense of oneself as male or female, regardless of anatomic makeup. Sexual orientation refers to one's heterosexuality, homosexuality, or bisexuality.
Is transgenderism a psychological or medical condition?
Patients who are transgendered may present with psychiatric symptoms such as anxiety, depression, or suicidal ideation, and they may be treated with psychotropic medicines for these symptoms. But such psychiatric manifestations are often traced to social stigmatization and rejection in response to the patients' cross-gender expression. Patients who receive counseling and medical intervention to help them transition to the opposite sex may no longer require psychotropic medications.
What medical treatment does Children's Hospital Boston provide for transgendered patients?
Children's Hospital Boston provides multiple treatments for a highly selected population of transgendered patients.
All transgendered patients at Children's, all of whom have been previously screened by psychotherapists skilled in evaluation of gender identity, are counseled and evaluated by a GeMS psychologist. Following an established international research protocol, patients undergo a series of psychological and medical tests in order to assess whether they have persistent clinical symptoms of transgenderism that interfere with their psychosocial function and put them at serious risk for self-harm. Patients are considered eligible for medical intervention when they fulfill the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender identity disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable, and live in a supportive environment.
Children's offers reversible medical intervention to a select group of at-risk transgendered patients in order to suppress their production of estrogen or testosterone, but only after these patients have entered puberty. This reversible treatment gives patients time to reach an age when they can decide, with their families, whether to begin cross-sex hormone therapy. If they decide not to transition to the opposite sex, pubertal suppression will be discontinued, genetic puberty will resume, and patients will inevitably attain full maturation.
If there are no contraindications, Children's provides cross-sex hormone therapy to patients who are taking puberty-blocking drugs and who choose to continue with medical intervention, as well as to a select group of patients who have been referred to the GeMS clinic after they completed or nearly completed puberty. Cross-sex hormone therapy (estrogen or testosterone) has some irreversible effects: estrogen diminishes sperm production in males, and testosterone causes females to stop ovulating and menstruating. As with all sex hormone therapy, including the sex hormone therapy Children's endocrinologists routinely provide to offset medical deficiencies caused by cancer and other conditions, patients are closely monitored for side effects.
Which drugs are capable of reversible suppression of estrogen and testosterone, and how do they work?
GnRH analogues temporarily suppress puberty by blocking release of gonadotrophins from the pituitary gland, thereby halting production of sex steroid hormones from the gonads. High dose progesterone works similarly but is less desirable because of its side effects, which include fluid retention and reduction in the adrenal gland's ability to respond to stress. GnRH analogues, which have been used for many decades to assist in reproductive treatment for women and to arrest precocious puberty in children, have not been shown to cause major side effects.
What are the health risks for transgendered youth who are untreated?
Transgendered youth, whether male or female, may be at serious risk for self-harm and often engage in life-threatening behaviors related to their transgender identity. Patients sense that they are "trapped in the wrong body" and many experience verbal or physical abuse as a result of their gender expression. Many transgendered youth report having seriously thought about taking their lives. Over 25% of the transgenedered youth who participated in a recent study had actually attempted suicide.
How does medical intervention offset the life-threatening behaviors of transgendered youth?
During the process of puberty, adolescents' bodies undergo irreversible or difficult-to-reverse physical changes. Among the changes produced by estrogen are breast development, menstruation, a female body contour, and earlier closure of growth plates (as compared to males). Among the changes produced by testosterone are facial hair, a male body contour, a male facial bone structure, spontaneous erections, a deepened voice, an Adam's apple, and larger hands and feet (as compared to females). Pre-pubescent transgendered youths are so distressed by the changes that will occur during puberty that they are at risk for self-harm, including suicide. Puberty-blocking medical intervention, offered only to patients who have already entered puberty, temporarily prevents the development of irreversible characteristics of the unwanted sex. This reversible puberty suppression treatment provides time for patients to reach an age when they can decide whether to begin hormone treatment that allows them to transition physically to the sex that matches their gender identity. Throughout this process, the GeMS medical team provides ongoing assessment and counseling. If patients change their mind about transitioning to the opposite sex, pubertal suppression will be discontinued, puberty will resume, and patients will achieve full maturation.
In the Netherlands, where more than 100 youths have been treated with pubertal suppression, 50 of whom have progressed to cross-hormone therapy, no patients have changed their minds about transitioning to the opposite sex. None has attempted suicide after beginning the protocol.
Does Children's Hospital Boston perform any surgeries that aid in gender reassignment?
No. Children's Hospital Boston does not perform any surgeries that aid in gender reassignment.
At what age can patients be referred to the GeMS clinic?
New patients of any age up to 21 can be seen at the GeMS clinic, if they have been previously screened by a psychotherapist skilled in evaluation of gender identity. Children's Hospital Boston does not accept new transgendered patients over the age of 21. The GeMS clinic can, however, provide such patients with information about psychological and medical treatment options at other sites.
Delemarre-Van de Waal, HA, Cohen-Kettenis, PT. (2006). Clinical Management of Gender Identity Disorder in Adolescents: A Protocol on Psychological and Paediatric Endocrinology Aspects. European Journal of Endocrinology, 155 (1), 131-137.
Grossman, AH, D'Augelli, AR. (2007). Transgender Youth and Life-Threatening Behaviors. Suicide and Life-Threatening Behavior, 37 (5), 527-537.
Hughes IA, Houk C, Ahmed SF, Lee PA, LWPES Consensus Group, ESPE Consensus Group. (2006). Archives of Disease in Childhood, 91 (7), 554-63.
Kreiss JL and Patterson DL. (1997). Psychological issues in primary care of lesbian, gay, bisexual, and transgendered youth. Journal of Pediatric Health Care, 11(6), 266-274.
Spack N. Transgenderism. (2005). Lahey Clinic Medical Ethics Journal, 12(3).
Zucker, KJ, Bradley, SJ. (1995). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. New York and London: The Guilford Press.