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Background
An adolescent with protracted trauma history and gender dysphoria in the setting of reported intersex diagnosis at birth (assigned female) and two-spirit gender identity presented to the pediatric gender clinic for initial consult. Familial goal was immediate gender affirming hormonal therapy with testosterone. Review of literature done in caring for this patient presented multiple holes in the in current pediatric gender affirming literature.
Case
Social work (SW) through a local community partner was involved prior to initial visit and identified complex psychosocial issues: suicidal ideation, potential mental health needs of mother, reported historical abuse by father, gender-identity related violence by peers, and medical distrust. Medical history, per patient and mother, was notable for ambiguous genitalia at birth with mother's decision to assign infant as female. History during adolescence was notable for reported clitoromegaly, hirsutism, deepening of voice, and secondary amenorrhea of 5 years. Per family, no workup had been done to date and no previous medical records were available. The patient did not assent to genital exam, however, the patient self-identified a Ferriman-Gallwey score of 21, chest SMR V, and genitalia matching a clitorophallus via images. Subsequent medical work-up included pelvic ultrasound with normal uterus, ovaries. No hormonal etiology for changes were found, including normal DHEA-S, Prolactin, Testosterone (free + total), estrogen, 17-hydroxypregnenolone, and androstenedione. Given normal medical workup and psychosocial support with SW, testosterone was initiated in accordance with patient and family wishes
Comments
There is a dearth of literature for patients who are intersex and identify as two-spirit. Collaborative SW support and medical care was key. SW was able to identify complex concerns and facilitate ongoing care: in particular, SW provided support surrounding the need for further medical workup prior to initiation of HRT, which was instrumental in familial engagement. Continued conversation identified cultural support needs related to Asian American and Tsalagi ancestry and two-spirit identity. SW was able to contextualize school advocacy support in the context of gender identity and historical persecution of Native American Students. Family was connected to a two-spirit society for additional support. This case highlights the need for more robust pediatric gender affirming literature and widespread use of multidisciplinary teams, particularly in providing culturally sensitive care to gender diverse youth.
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Copyright
© 2023 Published by Elsevier Inc.
