Straight Talk About Transgender Youth

A lot of recent media coverage has drawn attention to trans youth, and some revolutionary new techniques being used to treat them. This has sometimes been accompanied by hysteria and misinformation, and it is important to understand the changes in medical approach and how to assess trans youth needs.

What Transsexuality Is (A Primer)

"Transgender" covers a range of people, while transsexuality is specific to those who need to transition to and live as their identified gender, rather than their birth sex. Where a person is on this continuum and whether they need to make a life change is something that they need to search their heart and discover, which can take a lot of time (but also keep in mind that a child may have already spent a significant amount of time determining this before coming out to people as trans, too -- many know from a very young age). It is far more difficult for others -- such as parents, friends, counsellors -- to make this assessment, because children quickly learn from social interactions that variant gender identity and expression are frowned upon (often severely), and kids sometimes become very good at hiding their identity. Something that everyone can agree on is that this is not a decision to rush into. However, if it is a decision that has had a lot of introspection leading up to it and if a sense of desperation is present, there may be more emphasis on moving forward. Moving forward, though, doesn't mean rushing into irreversable body-altering situations right away.

Is This Real or Imaginary?

Treatment of transseuxality has been studied since the mid 1900s. While we don't yet know the full reason why some people have an identity that does not match their birth sex, studies in recent years have demonstrated a likelihood of a biological component or origin (the link is just one of several such studies) -- and shown how gender identity and physical sex develop at different times in utero (and occasionally develop incongruously). Additionally, as much as people would like to believe that anti-psychotic drugs, conversion therapy and ECT would help transsexuals "just get over it," modern medicine has realized that this approach simply does not work, and usually results in self-destruction, suicide or extreme anti-social behavior.

Aligning body to mind, however, has enabled transsexuals to become valued and successful people in society (MTF and FTM examples). That is why the standards of care set by the World Professional Association of Transgender Health (WPATH) recommend transition and surgery - as also supported by the American Psychological Association, the American Psychiatric Association, the American Medical Association (link is most recent affirmation) and the Canadian counterparts of all three.

Why It Is Far Better to Address Transsexuality During Youth

The onset of puberty brings life-altering changes, sometimes very severe ones. Hormones can make radical changes to one's body, and also bring significant distress and panic, if those changes are contrary to a child's identity. For someone who is female-to-male transsexual, for example, the development of breasts or the onset of menstruation can lead to severe depression and self-loathing. Testosterone significantly affects a body as well, causing irreversable effects, such as a significant deepening of voice; the development of an adam's apple (trachea); growth in height, size of hands and such; harsh masculinization of facial features and bone structure, the onset of hair loss, propagation and thickening of facial and body hair and a deepening of the chest cavity. If left to adulthood when transition is necessary, these will create significant obstacles for a child, and in some cases require extensive corrective surgery -- in other cases, they cannot be corrected at all, and will remain permanent obstructions to presenting and being accepted in society. For transsexuals who pass through adolescence without treatment of any kind, the risk of suicide is very high, with many surveys showing a high percentage of attempts made at that time by transsexuals who transition later in life (surveys are often hampered by limited numbers of participants, differences in who is included -- i.e. transsexuals only or all transgender people or all gay/lesbian/bisexual/transgender people -- inconsistencies or limitations of questions, and biases of researchers, so it is impossible to point to a definitive survey, and only a general pronouncement can be made based on an average of conclusions). [From an anecdotal standpoint, as someone who has been very involved with the transgender community, I can assert that suicide attempts during the teen years are more common than not making any such attempts -- Mercedes]

What The New Treatments Do

The following is not to be taken as medical advice -- it is meant to initiate discussion that you can later take up with a trans-friendly doctor ("trans-friendly" is important, as not all doctors treat according to the WPATH SoC, and some therapies, such as aversion therapy, can be extremely harmful)

It should be noted what the new treatments of trans kids do not do: rush. Surgery is generally not prescribed until a child has reached a reasonable age to make such a decision -- age 18 is the most common benchmark; the youngest-known recipient of surgery was a 16-year-old pop singer in Germany, and this is not common. Several years of living as one's identified gender are also required before surgery can be performed. Overall, ample time is given to allow children to outgrow feelings of transsexuality, as well as through life experience, before GRS and induction of body-altering hormone therapy (which is not to be confused with puberty-blocking drugs) become options.

The newer practices involve the prescription of puberty-blocking drugs for a length of time, while a child lives as their identified gender. This prevents the negative changes from taking place while a child acclimates him or her self to their identified gender role and presentation, and gives the child sometimes years to become certain that they are making the correct decision (transition in adulthood requires 1 year of real-life test by the WPATH standards of care, so this is actually a far more cautious procedure than otherwise typical). These blockers will only delay puberty, and can be stopped at any time to allow regular puberty to take place, if a child changes their mind. Unlike the use of these blockers in adulthood, these can be used with children for a longer amount of time before things like sterility become an issue. Cross-gender hormone drugs can later be used to induce puberty for the child's identified gender when the child, parents and therapist are all secure with taking that step.

In most cases (especially with male-to-female blockers, where they have also been used with transsexual adults for many years previously), these puberty-blocking drugs have been around for long periods of time, and their effects and potential side-effects are well-known. The only variable of concern with these is that some have less information as to any potential side- effects that might be aggravated by puberty -- for this reason, regular blood tests to monitor endocrine levels are taken, recommended for every three months, especially in the first few years of therapy (and should continue into adulthood with at least some degree of regularity).

For male-to-female patients, the hormone blocker used will often be Spironolactone, although Androcur (more common in Europe) or Finasteride may sometimes be selected (Flutamide is also an option but is considered by some to be a bit more experimental). For female-to-male patients, the field is more diverse on selection, with GnRH agonists (Lupron, Zoladex or Suprefact) or GnRH antagonists (Plenaxis, Cetrotide or Antagon) most recommended. Depo-Provera (medroxyprogesterone acetate) is sometimes used, but with less support in some circles. Note that many of these medications have different names for their generic equivalents or related / derived medications.

Something that is sometimes forgotten in this process is that if the child will want to one day have biological children, it will be necessary to obtain and freeze ova or sperm before cross-gender hormone therapy commences.

When It Is Time To Move Forward...

... issues are very similar to those for transsexual adults, but pubertal changes (some of which might have required surgery or creatd permanent obstacles) and disruptive life changes (i.e. transitioning while one is building a career) have been avoided. Cross-gender hormone therapy can commence, usually in mid-teens, with some guidelines specifying 16 as a benchmark age, and surgery can be discussed as the youth reaches adulthood.

Links For Further Research

• Draft of The Endocrine Society Treatment recommendations for transgender persons, both child and adult.
• Gender Identity Research and Education Society (GIRES) recommendations regarding caring for transgender youth
• New Scientist article about varying opinions on the use of puberty blockers