Since 2007, the Gender Management Service (GeMS) Clinic at Children’s Hospital Boston has taken an interdisciplinary approach to treating the medical and psychosocial issues of infants, children, adolescents and young adults with disorders of sexual differentiation (DSDs)—medical conditions in which normal sexual development doesn’t occur. DSDs can interfere with sexual and reproductive function and make it difficult to determine a patient’s sex.
The GeMS clinic is the first major program in the United States to care for children and young adults who are transgender—a rare condition in which a biological male or female with no known anatomic or biochemical disorder feels a strong identification with the opposite sex. Such feelings can emerge early, even in the preschool years, and can cause considerable psychological distress.
Some of the conditions for which GeMS provides medical and psychosocial treatment include: ambiguous genitalia, intersex disorders, congenital adrenal hyperplasia, hypospadias and epispadias, androgen insensitivity syndromes, Klinefelter
syndrome and its variants, vaginal agenesis and Mayer Rokitansky Kuster Hauser (MRKH) syndrome and transgenderism (gender identity disorder).
The majority of patients with DSDs—conditions that can be congenital, genetic or have no known cause—have had diagnostic procedures prior to referral to GeMS. If not, GeMS coordinates appropriate testing.
For patients who may be transgender, the GeMS clinic offers the most intensive psychometric testing available for gender identity, applicable from childhood through young adulthood. Testing involves a four-hour psychological and gender evaluation to identify any psychiatric issues and determine the degree of gender dysphoria. The evaluation consists of a clinical interview with the child and parents, along with a battery of psychosocial and gender-related measures.
The GeMS clinic works closely with patients and their families to find the treatment that works best for everyone involved. Many children and youth with DSDs seek consultation about hormone replacement therapy and reoperation to improve appearance and functionality. GeMS staff also evaluates current treatment to make sure treatment is optimal.
GeMS works in conjunction with the pilot gender and sexuality psychosocial program in the Department of Psychiatry, which offers consultation and treatment options for a wide spectrum of sexual minority youth, including pre-pubertal children who may ultimately be transgender.
GeMS offers medical interventions for early-teen transgender patients. Before medical intervention, patients must undergo a rigorous series of psychological tests. Youth just beginning puberty who meet the stringent criteria may qualify for puberty-suppressing therapy, a nonpermanent medical process that delays some sexual characteristic development. Monthly injections or a temporarily implanted drug may be given to block sex hormones. This treatment allows patients to grow in a neutral state without developing the irreversible physical characteristics of the gender that they reject. It’s fully reversible at any point.
At age 15 or 16, patients are vigorously retested. Most choose to continue to the next stage of treatment and begin taking the hormones of the opposite sex. This produces physical attributes of the opposite sex (like breast development) and is largely non-reversible. The last state of treatment is gender reassignment surgery. GeMS does not offer this service; however, we refer patients when they are over age 18.
The GeMS clinic is researching the demographics of the clinic’s patient population to determine trends in age and gender. They are also studying the prevalence of self-harming behavior in the transgender patient population, along with patients’ self-reported perception of the reasons for these behaviors and thoughts. Future research includes a study on the effect of pubertal suppression on the endocrinologic, metabolic, physical and psychological outcome of transgender patients.
Norman P. Spack, MD
Laura Edwards-Leeper, PhD
Scott Leibowitz, MD
Child and adolescent psychiatrist
David A. Diamond, MD
Francie Mandel, MSW, LICSW
Rosemary Grant, BSN, RN
Make a referral: 617-355-7476 and ask for Kim Withrow