Transgender youth treatment and bone health

Increasing rates of school-aged children and young adults are identifying as transgender individuals. There are currently no specific nutrition guidelines on the care of transgender youth, so you may be asking – what do I need to know to care for these patients? 

What is transgender? 

Transgender describes an individual that experiences a disconnect between their gender identity and the sex assigned to them at birth. This identity can be fluid but is the internal sense of feeling male, female, neither, or a combination of both. A few common terminologies are used to described trans youth: 

• Transgender boy (trans boy): assigned as a female at birth, but identifies with masculine gender identity 
• Transgender girl (trans girl): assigned as a male at birth, but identifies with feminine gender identity 

Gender-Affirming care 

Youth who aim to transition undergo physician-supervised care, which includes gonadotropin-releasing hormone agonist (GnRHa) therapy to prevent pubertal development. They may also be treated with cross-sex hormone therapy to promote opposite sex characteristics. For example, trans boys may undergo testosterone therapy, which promotes the growth of facial and body hair and gains in lean muscle mass.  

Trans girls, on the other hand, will undergo two types of hormone therapy in addition to GnRHa: an anti-androgen to decrease testosterone and estrogen-promoting therapy. Trans girls will not develop facial and body hair through puberty and may see declines in lean muscle mass. 

Trans youth and bone health 

GnRHa therapy puts trans youth at risk for poor bone growth and density as this type of therapy impairs the increase in bone mineral density (BMD) that occurs during puberty. Even after only one year on GnRHa therapy, both trans girls and trans boys may see declining Z-scores less than -2 in the hip and spine.  

Introduction of cross-sex hormone therapy promotes BMD increases as they mature. However, up to 40% of trans girls and 5% of trans boys will still have a BMD Z-score less than -2 when they reach adulthood. Early onset osteoporosis is a growing concern for practitioners, but unfortunately, there is limited longitudinal data predicting fracture risk and other long-term outcomes in these patients.  

Nutrition care for trans youth 

Even though there are no specific nutrition guidelines for transgender patients, no data exist against recommending adequate calcium intake, and if necessary, vitamin D supplementation that would typically be recommended to pediatric-aged patients. The Endocrine Society and International Society for Clinical Densitometry do not advise systematic assessment of BMD until risk factors for osteoporosis exist, but growing evidence suggests a lower threshold to perform a dual energy x-ray absorptiometry (DXA) scan in this population to mitigate long-term risk.  

Working within your care network to advocate for the proper nutrition assessment of transgender youth can help address the need for dietary or supplement intervention. Additionally, initiating discussions with your care team on establishing clinic or facility guidelines can further enhance the care of these patients.  

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References: 

Verroken C, Collet S, Lapauw B, T’Sjoen G. Osteoporosis and Bone Health in Transgender Individuals. Calcif Tissue Int. 2022 May;110(5):615-623. doi: 10.1007/s00223-022-00972-2 

Stevenson MO, Tangpricha V. Osteoporosis and Bone Health in Transgender Persons. Endocrinol Metab Clin North Am. 2019;48(2):421-427. doi:10.1016/j.ecl.2019.02.006 

Rothman MS, Iwamoto SJ. Bone Health in the Transgender Population. Clin Rev Bone Miner Metab. 2019;17(2):77-85. doi:10.1007/s12018-019-09261-3 

El Miedany, Y. Bone Health in the Transgenders. In: El Miedany, Y. (eds) New Horizons in Osteoporosis Management. Springer, Cham. 2022. https://doi.org/10.1007/978-3-030-87950-1_6