Thank you very much.

That was excellent, and now

I have the pleasure to introduce a

Doctor Latif

Chair Pediatric Endocrinology here,

who has

fortunately been a part of our

program since

just after the beginning, because

when we started this, we had

obviously very little experience.

And I thought personally

that kids are a lot harder

than adults and there's a lot more

issues. And you got to deal with

parents and I don't

know anything about that.

And, you know,

so we'll we'll try to get it going

for adults and then

will expand to children and

adolescents. Well,

the minute we opened, we were

getting tons of referrals

for children, adolescents,

and I just couldn't turn him away.

So he said I.

I said, look, I don't know what I'm

doing, but we'll see you and we'll

get you to the right place for what

you need to do.

And fortunately, we've been able now

to tell people that they can stay

here if their children, adolescents,

and we can handle them very well

under the direction of doctor, the

chief from the medical side.

Good morning.

Thank you for spending your

Saturday morning with us.

The weather is gorgeous outside, so

I hope we can get out and

do something.

I have no

financial relationships

to disclose.

Really no disclaimers other than.

I keep learning the older I get.

I may not retain as much, but I'm

learning the more patience I see,

the more I learn.

So that's my only disclaimer.

Those are the learning curve.

Sex if we're going to discuss

puberty suppression.

Discuss the challenges, potential

side effects.

Then I'm going to talk about our

experience in the Pedes

clinic. And I'm going to talk about

some of the cardiometabolic risk

factors that are present

even before we start gender

affirming therapy.

And I'll also discuss gender

affirming hormone therapy in

adolescence. I only have twenty five

minutes, so

I'll try to be very efficient.

I always like to start with a

quote.

And because my kids

are older and not as cute, I

usually don't have pictures and

quotes from them.

So pick something else.

And this is from the Putsy Press.

And basically it says

Grown ups never understand anything

for themselves.

And it is tiresome for children

to be always and forever

explaining things to them.

It's true.

We have to deal with it every day.

So why is it important

that we do what we do?

Actually, this was a study that was

done by one of our

med students and Dr. David

Spitz. And we looked at really,

you know, the incidence and of of

of depression and

at onset county.

And this is youth up to 21 years

of age.

And you see the numbers are,

you know, pretty impressive.

Meaning that seventy point six

percent of kids

had a diagnosis of depression.

Anxiety was sixty one point eight

percent. Suicidal ideation,

sixty point seven percent.

And it goes on and on.

But I think when we see those

numbers, it is hard not

to do something

about it. Those numbers are even

more impressive than what's been

published. And, you know,

the general literature.

So we need to help

these kids for sure.

So I'm going to start with J.

J. First reported.

Incongruence between the sex

he was assigned at birth and his

gender identity at the age of three

and before entering gender guard.

Then he made a full social

transition and a name change.

J is interested in puberty blockers

as he is having

really increased

dysphoria around the thought

of his body changing

with puberty.

He is in Tanner stage one,

but he has pimples and he

has body odor.

Is Jay ready for puberty blockers,

Mom? Once puberty

blockers a.

S a p.

And this is a real case.

The name is the friend, but we see

that all the time.

And I personally see it more

in the kids who have made an early

transition that sometimes

the parents are extremely

worried about the idea of

even letting puberty start

and stopping in at an early

age. So I do have pressure

sometimes from the parents, and it

is hard to tell them that, listen,

puberty can happen at HP but

can happen at age fifteen or

sixteen.

So to stop something that hasn't

happened for six years is not

a good idea.

Plus, it's not a good idea for other

reasons as well.

But it is a hard message to sell

sometimes.

And I think, you know, so my

attitude is if we're having

a lot of issues around that, then I

send them back to our behavioral

specialists so they can work not

only with a child, with a parent

as well.

So what we need to do, what

we need to know about puberty is

should we suppress it?

Where are the options for medical

therapy? What are the side effects

and what are the benefits of

puberty suppression?

The first thing that we have to talk

about is doing a physical exam.

And I always start with,

you know, few Baqi

or Adrienne Archey is not equivalent

to puberty.

So even if we use puberty

blockers for

pubic hair development, we may

not be doing a thing.

And that's why it's important to do

a physical exam.

I'm not saying I have to

do a physical exam the first time

I see the kid, because a lot of

these kids are scared and they're

hesitant. They don't know me.

Sometimes I see them the first time.

The second time I get child life

and we work through different issues

to be able to do an exam.

But it is difficult to start

puberty blocker without

a physical without a physical

exam. Some people advocate

for getting, you know, hormonal

tests like an H and F message.

But again, the range for Estra

dial and even if

we have the ultra sensitive essays,

can be huge.

Between panners stages one

and three. So sometimes just getting

LAVs is not good enough.

And I don't do any, you know,

invasive physical exam.

I you know, we tried

to get the child life and oftentimes

it's not an issue, but this is

something that we need to be aware

of. So if I have a child that's

telling me I have body

odor, it does not necessarily

mean that they started central

puberty and we need to be aware of

that. So we do need to

do a physical exam.

And those are the parameters that

I've outlined.

Again, the treatment is reversible

and we can always

puberty blockers, even when puberty

is fully established.

The benefits may be a little bit

different.

But certainly we could use

it. That picture, the first

one is an orchid ometer.

We don't have to have one.

We can use a measuring tape because

the first sign of puberty

in, you know, boys is

testicular enlargement.

So at some point, it is important

that we really know how to assess

puberty.

People have talked about that

before, when to start.

We do follow the W path guidelines.

So the G and our H analogs.

What are they?

So basically they're a substitution

of the Gennari.

Monaco.

And if we give them in a

pulsatile in a non pulsatile

fashion, basically we inhibit

the FSA to now each release.

We always have to tell patients

that when we do that, there may be

initial stimulation before

inhibition. Meaning that you might

expect a little bit more.

There might be another,

you know, monthly bleeding before

we suppress it.

And it's important to tell them that

because we don't want them to be too

disappointed.

So they need to know that

there could be.

Stimulation before.

Just some things about the

Pedes preparation

versus the adult preparation.

I've treated early puberty for

the longest time and we've always

used Depo Pedes

when I asked the pharmacy to look

at the Papeete and

therefore not Pete.

Really, they're not much different.

And we even compared the similar

active and non active ingredients

and they're not much different.

But the cost can be.

Hugely different.

And it's important to keep that in

mind. And this is a quote that I got

from a pharmacy from two years ago.

And, you know, yes, that eleven

point two five dose of therefore

Lupron is the one that we use most

commonly. It's not much different,

is a little bit different.

But when we look at the other

preparations, like the,

you know, the DEP Pete, 30 mg,

it's about seven thousand dollars.

And the adult.

Sorry I missed the D.

It is about four hundred and seventy

eight. The adult, you know, 30

milligram used for, you know, every

four months is the one that we use

for prostate cancer.

Can I use it in Pedes.

I'm not going to tell you what I do.

But this is something to keep.

This is something to keep in mind.

Because sometimes if you have to use

something and cost is

prohibitive, you really

have to be innovative about it.

I mean, we do do a few letters.

And my experience is most

commonly those

puberty blockers are approved.

But there are situations where,

you know that the

families may have to do some

digging.

And because I've had patients who

would have coupons for

any guards rather than that

blueprint. So they have to do some

search and sometimes we can get them

for, you know, cheap,

even if insurance is not

paying for them.

So always do some

problem solving.

All that I'm saying is

there is a theoretical difference,

but I'm not sure how big of

a difference that

it's.

There are other agonists.

I'm not going to discuss all of

them. There is the his Trelane

implant.

This actually the cost is a lot more

at Mayo. This is done when we put

the Australian implant.

We do it under anesthesia.

I know. And other clinic, they do it

in the local office.

But that gets that adds to the cost.

So I haven't done a lot of his

Trelane implants for

transgender

kids.

And then for early puberty tripto

land that has been approved.

And it's a you know, it's given

every six months.

It's a little bit harder to get.

But this is something to even

even if it's more expensive,

it's given less frequently.

So I think the costs may be a little

bit less. So we could use all of

these things.

Again, the benefits are,

you know, preventing the development

of, you know, breast tissue,

facial structure, voice

than even if we start

in Tanner stage two or three,

as Dr Tranz said yesterday,

even if we were to do chest surgery,

I think it may be easier to do it

when there is a small cup size than

a big cup size.

So even even if puberty

has because we're not going to start

Lupron if Cuba hasn't started.

But again, I think the need

for more aggressive surgeries is

going to be less once we start

puberty blockers.

And this is the roadrunner.

I watched it a lot when I was

younger.

But again, this is the trick

is how often do we examine these

kids? Because sometimes.

There should be something out here

we go.

So then one,

no puberty, five fully

developed.

And sometimes you have kids who

develop puberty and zoom

through puberty very quickly and

some will spend a lot of time

through puberty.

So, again, especially when

when we're talking about trends,

girls and the need for

future surgeries and vaginoplasty,

there may be an advantage of waiting

until, you know, 10 or three

is fully established.

But the question is, there is a fine

line between 10 or three and 10

or four.

And we want to try to do things

before the voice changes.

So I think it is important to see

these skits pretty frequently

because the time frame

between each stage

is a little bit hard to define.

It can be very quick or

it can be very long.

And I think that's something that we

cannot predict.

The first time we see a patient.

So, again,

that's this is arranged when

we need to try to do something

about about puberty.

So the psychosocial benefits.

There was a the first study was

from 2011 and it was an

old study. But unfortunately, in

kids, we don't have

a lot of evidence based medicine.

And I remember one time we're not

talking about, you know, the

transgender literature, but more of

the bone literature.

And somebody told me, listen, you

know, it was regarding

bisphosphonates.

If you want to wait to have

evidence based medicine in kids.

Sometimes you end up doing nothing.

And in part, it's true because it

takes a lot longer to do studies

and kids.

So sometimes we have to be more

proactive than passive.

I would say so when when

puberty blockers have been used,

there was a reduction in symptoms

of depression and global functioning

improved.

But again, some of the measures of

dysphoria and anxiety did not

change.

There was a most recent study that

also looked that psycho psychosocial

score. So to zero was the baseline

evaluation between

zero and six months.

There were, you know, more

psychological support.

And then the groups were divided

into puberty blockers

and no puberty blockers and

and the kids who did receive purity

blockers.

That's even better.

So there might be improvement.

And so there is improvement in

psychological scores

on puberty blockers,

some of the side effects that we

need to be aware of.

I have a picture of the

sterile abscess and I have seen

a lot of kids go to the emergency

room and have unnecessary treatments

because people think it's a

big act, says sometimes they end up

being admitted.

So we need to make sure to tell them

that this is a complication that can

happen.

I usually don't like that we're too

proud to be given at home.

I because some some

kiddos have moms who are nurses

and

yes, they can give it, but I

don't know my personal preferences.

Have somebody else give it

there.

You know, those are the concerns

that I'll discuss.

But then there's also the low bone

density concerns.

And this is a study that shows that

once, you know, puberty

blockers are started, the bone

density does decrease.

One's gender affirming

therapy, you know, is

that the bone density increases.

It does not go back to baseline.

So it is thin, low.

The question is, would these

kids reach peak bone density

later? So it's just that

it's like late bloomers were a

little bit behind everybody.

It's something that we have to see.

I do bone densities on

all of the kids who are going to be

on puberty blockers.

And recently, I had a very

interesting discussion because I got

a call from nuclear medicine and

because when I do bone density, I

do, you know, like the Pedes

bone density. And it gives me also a

body composition.

And so they were asking

me, you need to tell us what

normal's we need to use.

And if I'm just starting puberty

blockers, I use the, you

know, the the

sex assigned at birth norms.

But then as we start hormone therapy

and if this is something that I kind

of put it in my comment, please

give me both reference ranges.

And this is what they're starting to

do right now.

I cannot tell you what the outcomes

are going to be. This is something

that I'll probably look at years

down the road.

But this is something that I'm

starting to do right now.

And again, when we talk about

puberty blockers and,

you know, weight gain, this is

something real in

in in in both situations.

We have an increased percent

fat and a decreased percent

lean body mass.

So this is something that we need to

be aware of.

So I always tell the patient that

they might see a little bit

of weight gain on the puberty

blockers.

And right now at Mayo, we have a

body composition analyzer on

16.

So I do it on a.

At baseline, and then again,

I do it at every follow up visit.

I'm not sure what I'm gonna do with

the information, but this is

something that I'm starting to track

as well to kind of see with

before hormone therapy, after

hormone therapy.

What are the things that are

changing? The more we know, the

better it is.

And those are benign things.

They're of no cost to the patients.

So I'm doing those

the height.

I really don't think puberty

blockers.

Changed the height significantly.

This is a this is

a graph

of a patient of mine who was started

on puberty blockers around

that time.

So she was so it's a trance

girl. She was around the 75

percent that started puberty

blockers.

The rate of growth slowed down and

then was on gender affirming

therapy and that are being in the 75

percentile, which is

roughly where she started at before.

So I really don't think that

puberty blockers should be used just

from a height standpoint.

You know, there are concerns

regarding, OK, kids

are supposed to go through puberty.

What are we doing when we're

suppressing that?

And there are not many studies right

now. The feeling is that

with puberty blockers, we don't

have any significant detrimental

effect on executive

function, but

we probably need more data regarding

that fertility.

I, I am trying

to send every kid to our

gynecologist and Pete's urologist

because I think the field has

evolved so much.

And yesterday I had a very

interesting conversation with Dr.

Khan.

And we're talking about, OK,

when we're arresting, you

know, puberty at a very early

age, what are we doing?

What are. And what's he sending me?

It's kind of, you know, the ovaries

go to sleep.

And we had that

analogy of, you know, Sleeping

Beauty. Then they wake up and things

are fine. But she doesn't age.

And the ovaries age.

So basically, even in his idea,

if we start if we start puberty

in 10 or two and then

we you know, we can have

fertility even.

So even if we start puberty and

then gender affirming therapy

and then we discontinue that 10

years down the road, fertility is

still possible at male.

There are programs for fertility

preservation in pre pubertal,

you know, boys and girls.

So this is something that I'm doing.

I'm trying to do more consistently.

People are getting more

open to the idea of seeing a

fertility specialist.

So I would recommend that this be

done and discussed, I

think, with every family.

The induction of a man or

a couples puberty,

we can use oral contraceptives.

A lot of my patients are very

hesitant because a lot of them, a

lot of the trans boys say, all

right, I don't like the idea of

estrogen. It's just the idea of

estrogen that they don't like.

So, again, this there

still could be some spotting, but

it's a very cheap alternative.

The problem, it's not a problem

that I have with that.

But I'll show data that a lot of

our patients have cardiovascular

morbidities.

And a lot of the time, even in

patients with a high body mass

index, it takes a higher dose,

you know, birth control to stop

the monthly bleeding.

So some sometimes

we'll have to deal with more side

effects. So I what I've

been doing more is sending them to

gynecology and basically

trying to

do an IUD, which I think

is a safe.

And,

you know, is a safe alternative.

And at Mayo, it's done under

anesthesia. So, yes, we

can use Madrak supertaster on

acetate. I am I don't like it

too much because I think it causes

weight gain and low bone density.

So I am moving away

from that more

and I'm sending them for, you

know, IUD devices.

Let's kind of move on quickly to

16 year old Chris.

I met him when he was 15 years

old. There is a history of anxiety

and depression and

there is legal custody by parents.

Even though Chris rarely sees his

father, therefore, Lupron

was denied by insurance.

He was started on progesterone, but

he's now interested in gender

affirming therapy.

So he met WPX

readiness criteria.

We tried to reach this dad and tried

and tried. Well, finally, we have

we send letters

certified.

They were translated.

The father never attended a visit.

And in that situation, we felt that

we could move on.

And we started him on therapy.

I just want to share, you know,

data about our patient population.

And again, this is from 2015

to 2017.

We have a lot more patients right

now. I'm not sure that,

you know, the data has changed.

But again, we looked at,

you know, blood pressure.

This is before any puberty

blockers, any gender affirming

therapy.

And if you look, there is a

significant number of patients

with with high blood pressure,

either in the pre hypertensive

or hypertensive range.

Same thing with overweight and

obesity.

So if we look at that graph,

the severe obesity, which is defined

as being great at.

Out of more than the 99 percentile.

We had fifteen point three

or eleven point nine percent of our

patients fit in the severe

obesity category.

So a lot higher than

this gender population.

Same thing for the rate of this

lipids. So you kind of look

a lot of patients with low HDL.

A lot of patients with abnormal

liver enzymes.

I've been sending a lot of my kiddos

to G I and

a lot of them have fatty liver.

So this is something to be aware of

before we start hormone therapy.

So gender affirming therapy and

trend, trans masculine youth.

I like this dosser on in Faith

and SAPIEN eight given

subcutaneously.

I've had a lot of patients who

wanted to try the gel first.

I have a hard time having insurance

approved the gel.

And, you know, teenagers, they're

not very good at putting stuff

every day.

So most patients go

back to subcu injections.

And I think by far this is what I

use the most.

I have the doses here.

And again, if somebody is on CNR

each analog, we can start at a lower

dose. And I have the doses outlined

here.

If they're off the gender age, I

usually start higher doses.

I'm not sure that this is much

different. What I want to share with

you is patients

need different doses.

So we need to look at the patients

and each one is different.

So I have somebody who is doing

perfectly fine with 20 mg

of testosterone, stipulate

weekly and you could see the

levels of testosterone an extra day

all.

And then I have a 17 year old

with a BMI of fifty two who

needed 100 milligrams subcutaneously

weekly.

So you have to start with a dose

and you have to follow the dose.

But again, I think what happens in

kids who have a high BMI, you see

the extra day old values are higher.

I think a lot of that testosterone

is aromatase into estrogen.

So this is something that we have to

keep in mind.

But there is not a single dose

for each patient.

A 20 may be sufficient

for some.

Somebody else may need 100.

So look at each patient,

look at their cardiometabolic

risk factors and follow that over

time. This is another patient.

And I wanted to show you just

again, I think Caroline and

they've talked about that.

Now, I don't know how to.

So this is a patient who was really

afraid of hair loss.

And the interesting thing is when he

came to clinic and he told me,

I'm worried about hair loss, you

kind of see that the testosterone

level went down.

So I called him. I said, are you

trying to not take

your medicine to prevent hair loss?

And he said, Oh, I've been reading

about testosterone being converted

to THC.

So he was taking less testosterone.

So you have to always talk to the

patient when you see that the levels

are changing over time.

Again, I do monitoring

for the trans feminine youth.

I have I like patches

more than oral estrogen.

But a lot of patients like to go

with oral estrogen, with the

patches. Oftentimes we need more

than once

or that becomes an issue.

I've had a lot of denials with

the Estra Daniel Venerate.

I don't know if that's more

universal.

And I usually try to keep the levels

between 100 and 200.

And again, this is the

doses that I usually start

in transforming in youth.

So and those are the changes that

we see.

For feminising hormone therapy.

I monitor, I monitor

the prolactin. But I've never done

anything with that.

I don't like to use because who am I

because of the liver toxicity?

So I usually like to use spider on

the electron, especially when I

cannot use puberty blockers.

Those are my conclusion that

children and adolescents can be

offered puberty suppression

regardless of age.

We need to coordinate care.

The metabolic profile is suboptimal,

so we need to be aware of that

and follow these kids very closely.

And fertility preservation should

be discussed.

One last thoughts.

Speak to your children as if

they are the wisest, kindest,

most beautiful and magical humans

on earth for what they believe

is what they become.

Thank you.