Caring for the Transgender Adolescent: It Takes a Village

Christa is a 15-year-old male-to-female (MTF) transgender patient who comes to your Developmental-Behavioral Pediatrics office for consultation on attention deficit/hyperactivity disorder (ADHD) management and concerns about worsening anxiety. Review of medical history included mild persistent asthma managed with steroid inhaler and leukotriene antagonist. She was diagnosed with ADHD at 12 years and has been placed on methylphenidate and clonidine over the years with little improvement. She struggles in school, with barely passing grades, and feels that she cannot focus on her assignments.She was diagnosed with MTF transition gender dysphoria, social anxiety disorder, and depressive disorder at 13 years by a psychiatrist and was treated with sertraline with some mood improvement. More recently, she reports having thoughts of wanting to hurt people and "wanting to watch them wither away." She expressed being terrified by these thoughts, which lasted for a couple of days but have since resolved. She denied any suicidal thoughts recently and gives credit to her "best girlfriend" for her overall improved mood, improved sleep pattern, and increased energy level. She expressed having deepening feelings for this girlfriend but admitted to not having acted on these feelings as she is afraid of the consequences. She currently uses the pronouns she/her/hers.Family history is pertinent for paternal bipolar disorder. There is considerable psychosocial stress as Christa is estranged from her father, who is not supportive of her transition, although mother is. Unfortunately, she is dependent on her father for medical insurance coverage, and he is refusing to give authorization to proceed with the evaluations and diagnostic workup for the transformation. Christa has been repeatedly encouraged to seek counseling but has declined because of previous poor experiences with counselors. Her primary care clinician in Family Medicine has been administering hormonal replacement therapy because she cannot access the regional center of excellence because of above-mentioned insurance issues. She presents to you now with her mother for management suggestions and diagnostic clarification. What is your next step?