Adolescent Medicine: Part 1

How an American Subspecialty Went Awry

A New Subspecialty

Pediatric gender medicine centers in the United States are primarily housed in one of two subspecialty care divisions: endocrinology and adolescent medicine.

When a student is learning to become a doctor he or she is allowed to choose a specialty: pediatrics is one such specialty. Pediatrics is the specialty that is concerned with humans from birth to young adulthood. A doctor can then complete training for a subspecialty: adolescent medicine and endocrinology are both subspecialties.

Adolescent medicine is a subspecialty that was created in the United States. The first adolescent inpatient unit was opened in 1951 at Boston Children’s Hospital (Alderman et al., 2003). The first pediatric gender program was also opened in Boston, planting the seeds for the subspecialty’s shift toward affirming identities over addressing behaviors…so Boston WTH-stop starting things.

The first examination for sub-board certification in Adolescent Medicine was administered in 1994, “after several years of intense debate among many in the field” (Alderman et al., 2003). I don’t think that they could have predicted how intense the debates could actually get.

One of the primary goals of the field treating adolescents was to understand and address the high risk behaviors and limit the impacts of these behaviors on the patients and society. The great irony is that adolescent medicine providers are the very practitioners who were specialty trained to be able to identify high risk behaviors and socially mediated choices that adolescents are uniquely known to make. Many of these subspecialists are ignoring that training while affirming socially mediated trans, nonbinary, and gender queer identities in this patient population.

The field experienced a shift and went from offering guidance to parents toward a risk reduction model to aim their care directly at the adolescent. As we have seen, many parents report that once a child reaches this adolescent age, parents are asked (told) to leave the exam room for a series of questions aimed directly at providing direct care to the adolescent. A number of advances also increased this subspecialty field’s relevance: hormonal contraception, gynecological diagnostics, and an increased use of psychotropic medications. At completion of an intake triage for the pediatric gender center I would tell parents that the adolescent medicine provider could, “prescribe basic mental health medications, birth control for menstrual suppression, and works with patients with disordered eating concerns.”

Adolescent Medicine care includes: reproductive contraceptive interventions, sexually transmitted infections, disordered eating concerns, and treatment for anxiety, depression, and adjustment issues.

Adolescent Medicine Providers and Gender Care

Some of the more famous gender clinic providers are also adolescent medicine providers. This includes famous, “you can just get breasts put back on,” Johanna Olson-Kennedy, MD who is an Adolescent Medicine physician. This also includes the “you are just saying words” Yale assistant professor of Pediatrics, Dr. McNamara, who specializes in adolescent medicine.

In my hospital system we had a rotation for the adolescent medicine residents called ‘the advocacy rotation.’ A required part of this rotation included attending a Transparent parent support group meeting.

Transparent is a local group that grew nationally. A support group for parents with trans identified children and young people, facilitated by affirming parents. Attendance at this meeting was supposed to expose the rotating residents to the lived experiences of being a parent of a trans identified child and to build the familiarity with the parents’ and patients’ demands. This rotation didn’t just expose residents to parents’ experiences—it indoctrinated them into affirming demands over questioning them, a far cry from adolescent medicine’s original mission.

Depo Provera (DMPA)

In WPATH SOC 8, as one of their stellar high quality, evidence-based recommendations Statement 6.7 states, “We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy for breakthrough bleeding.”

In the center where I worked the vast majority of young women distressed about their sexed bodies who started with the adolescent medicine provider were prescribed depo provera (DMPA). I hate DMPA with a passion, and with good reason, starting way back in 2004 when I worked at a Planned Parenthood.

Depo is like taking a sledgehammer to a finishing nail. Complete overkill. DMPA is an injectable birth control that is usually given every 12 weeks. It is said to be good for those needing birth control who struggle with remembering to take a daily medication. Made by Pfizer, DMPA suppresses ovulation and thickens cervical mucus making it more difficult for sperm to reach an egg. It is progesterone based, not estrogen based, and we sold it to dysphoric young people as a menstrual suppression without estrogen. These girls often really just wanted testosterone but this was sold as a stepping stone in that direction. We also gave it at 11 weeks instead of 12—against standard protocol—because WPATH’s SOC 8 (2022) pushes flexibility for trans patients, a trend I saw prioritized over medical caution.

It gave the girls an immediate belief that they were getting something, and as adolescents, that was part of the demand: Give me something now and don’t make me wait. It also gave the parents relief that they were not getting testosterone, and therefore it was much more benign. In 2004, the FDA added a black box warning to DMPA for bone mineral density loss after lawsuits piled up (FDA, 2004). By 2024, Pfizer faced new suits linking DMPA to meningiomas, a brain tumor risk noted in a French study (Weill et al., 2021, BMJ).

DMPA has commonly occurring side effects as well. In clinical practice the side effects I have most commonly seen reported include: weight gain, mood changes, headaches, dizziness, decreased sexed drive, stomach pain, nausea and bloating, and ammenorhea (no periods) or dysmenorrhea (severe painful irregular periods). In the gender center practice, it was expected to see patients complain of dysmenorrhea after the first injection and the solution to that was to add an oral birth control to stop the side effect: bleeding from the injectable.

I grew to hate DMPA as a Planned Parenthood employee because patients simply despised it. They hated the nearly universal weight gain, they hated how it made them feel bloated and sick, made them feel emotionally crazy, and they hated that we told them it was going to stop their periods when, instead, they would often just end up bleeding like crazy, unpredictably. If we could get them to stay on it long term it would eventually completely stop their periods but in the short term it was usually a mess. The other problem with DMPA was that once it is in, it is in and there was nothing we could do to stop the side effects. Unlike a birth control pill which could be stopped quickly this, injection was going to be in you for months.

I worked for Planned Parenthood from around 2004-2008, and I had gotten away from the business of birth control for a number of years to find myself right back in the middle of it in 2018 in the gender center. Birth control is the adolescent medicine physician’s bread and butter. If you are seeing an adolescent medicine physician, strong guarantee you will be prescribed a birth control or an SSRI—but most likely both.

To be clear, I am not opposed to all birth control, I value women who have sex with men having options to manage their fertility. I accept that those options can be hormonal in nature and that for many women contraception is a part of their daily lives. But I also believe that the least amount of medical intervention that can be utilized should be. I take pride in having been the Planned Parenthood staff member who did—and still can—teach the rhythm method. I loved teaching women who had sex with men their fertility cycles, to understand their bodies. I can, without any shame, explain the differences in cervical mucus, cervical position, and opening to any woman to help them understand when they’re fertile. Still happy to do so over a gin and tonic, anytime!

The young women in the gender center—distressed about their sexed bodies—who were getting DMPA, were often, first of all, not having sex. None. Not with men, not with women. They reported—often—no sexual experiences at all, so there was no need for contraception to control fertility. They were also divorced from the physical realities of their bodies, often already overweight or clinically obese, not exercising, meeting criteria for disordered eating (often binge eating) and meeting criteria for depression and anxiety. But they claimed that they were boys, and boys should not bleed, so DMPA we gave them.

Menstrual Suppression

In 2022 the American College of Obstetricians and Gynecologists (ACOG) pronounced A-COG released a clinical consensus guideline to menstrual suppression. It recommended ways to use the various hormonal birth control methods in such a way to stop monthly menstruation. This was not a new concept in 2022: we knew how to counsel patients back in 2004 how to use their birth control to stop periods.

In the 2022 guidelines:

Transgender and gender-diverse individuals may benefit from menstrual suppression to decrease gender dysphoria associated with menses.

Transgender and gender-diverse individuals may benefit from menstrual suppression due to the association for some patients of gender dysphoria with menses. Practical considerations with menses in transgender and gender-diverse individuals include not only dysphoria with menses but also attitudes and safety concerns regarding public restroom use for menstrual hygiene

I am not surprised to read this statement, but it should be noted that the beliefs of trans cross over into all medical specialities. ACOG’s statement is taking for granted that women who claim a male identity will be in men’s public bathrooms dealing with menstrual hygiene. But back to menstrual suppression and ACOG.

Gender-affirming hormone therapy with testosterone can be used to achieve amenorrhea. Gynecologists should counsel patients with reproductive potential who do not wish to become pregnant about the contraceptive efficacy of suppression options.

Use of testosterone for gender-affirming hormone therapy is associated with amenorrhea, which is commonly achieved within a few months of initiating therapy. Continued bleeding may be treated with the addition of progestin-only therapy to achieve amenorrhea. Most studies demonstrate endometrial atrophy with the use of exogenous testosterone as part of a gender-affirming protocol.

So ACOG offers testosterone as a way to reach menstrual suppression, but also that even on T, if bleeding continues, one should add even more hormones, through a progesterone-only therapy. DMPA is one of those. Note the mention of atrophy.

Adolescents are a part of ACOGs guidance and they recommend that even for adolescents, menstrual suppression is safe and can be effective, but especially for those who are trans-identified, which is part of why we see gender centers with big numbers of young women on DMPA.

Menstrual Suppression: Is It Safe?

Women used to have far fewer menstrual cycles in the past than we experience now. “Prior literature suggests pre-industrial women menstruated approximately 100 times/lifetime due to extended pregnancy and breastfeeding periods; however, contemporary Western women menstruate nearly 400 times.” (DeMaria, 2019)

All women of child bearing age will have a numerical score called a gravida para score. The score is calculated with two numbers: first is the gravida score (G) which is the number of pregnancies. The second is the para score (P) which is the number of live births. It can be expanded to include preterm births and abortions.

My score is G5P2, and expanded it is G5P2A3 due to my three miscarriages. I have been pregnant five times but have had two live births. I then breast fed my two children for what would be considered an extended period in the United States, the first for approximately 1 year and the second for approximately 3 years (most women breastfeeding on demand will not have periods while doing so). Because of my pregnancy and breastfeeding periods I will have many fewer menstrual cycles over my lifetime then women who are never pregnant or breastfeed. However if I lived hundred of years before and was not burned at the stake for my same sex attraction and instead was married to a man (and having an affair sleeping with the milk maid) I would have been pregnant most of my reproductive life and breastfeeding the rest of the time. In other words, if I’d lived centuries ago, frequent pregnancies and breastfeeding would’ve naturally suppressed my cycles—no DMPA needed.

This is the premise under which menstrual suppression is deemed safe, effective, and appropriate for adolescent girls, especially those identifying as male.

It’s a crude pretense that we are following the natural world, but now at least you know why it’s sold as it is. And frequent menstrual cycles do have negative health outcomes- higher rates of ovarian cancers, endometrial cancers, and breast cancers. But it remains unclear whether a shot of DMPA every 12 weeks provides the same benefits of extended pregnancy and breastfeeding cycles.

Part 2 unravels two insidious threads of adolescent medicine: a dangerous slide into minors’ consent that erodes safeguards and a wall severing parents from their teens’ medical secrets.

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Alderman, E., Rieder, J., & Cohen, M. (2003). The history of adolescent medicine. Pediatric Research, 54, 137-147. https://doi.org/10.1203/01.PDR.0000069697.17980.7C

DeMaria, A.L., Sundstrom, B., Meier, S. et al. The myth of menstruation: how menstrual regulation and suppression impact contraceptive choice. BMC Women's Health 19, 125 (2019). https://doi.org/10.1186/s12905-019-0827-xVirtual Mentor. 2005;7(3):249-252. doi: 10.1001/virtualmentor.2005.7.3.msoc1-0503.

Sapir, L. (2023). The pediatric gender industry. City Journal. https://www.city-journal.org/article/the-pediatric-gender-industry

U.S. Food and Drug Administration. (2004). Depo-Provera (medroxyprogesterone acetate) black box warning: Bone mineral density loss. U.S. Department of Health and Human Services. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/depo-provera-medroxyprogesterone-acetate-injectable-suspension

Weill, A., Nguyen, P., Labidi, M., Cadieux, B., & Froelich, S. (2021). Hormonal contraceptives and meningioma risk: A French cohort study. BMJ, 374, n1982. https://doi.org/10.1136/bmj.n1982