NEW HOPE, Pa. (AP) — For transgender children and their families, knowing if and when to begin the transitioning process can be an agonizing decision fraught with physical, social and psychological concerns.
Until the past decade, transgender people had to wait until adulthood for surgery and/or hormone therapy to physically change their bodies to match their identifying gender. But today's transgender youth have new medical options that can allow them to start the process at a much younger age.
Hoping to ease the emotional and psychological pain of kids who don't believe their birth sex fits who they are, some doctors have begun offering hormone blockers to families who chose to interrupt puberty for their transgender children.
The drugs, called gonadotropin-releasing hormone analogs, freeze development before a child begins showing signs of secondary sex characteristics such as voice changes, genital enlargement and breasts. While the drugs have been used for years to treat premature puberty, using them for transgender children hasn't been approved by the federal Food and Drug Administration and remains an "off label" use of the medication.
Suspending puberty allows the child time to explore the gender identity he or she feels is the correct one, without the crisis that puberty can bring for transgender kids, explained Dr. Norman P. Spack, associate clinical professor of pediatrics at Harvard Medical School and a founder of Boston Children's Hospital's Gender Management Service.
Typically, pediatric endocrinologists recommend a prepubescent child complete a year of psychological therapy before receiving such treatment. As with any medical treatment for someone under age 18, parental consent is required.
Dr. Christine McGinn, a New Hope-based plastic surgeon specializing in transgender surgery, believes strongly that early identification of gender dysphoria, in which people believe their born gender isn't their correct one, can spare transgender children a great deal of anguish as they grow up.
Despite society's increased understanding of transgenderism, transgender people continue to risk assault, loss of jobs, loss of their children and other family support, when the transition comes later in life and being accepted as a trans male or female may be more difficult, the doctor said. "If they can identify (as transgenders) as a child, all that can be prevented," said McGinn.
However, some question whether a preteen or young adolescent is able to fully understand hormone-blocking treatment.
Arthur Caplan, of New York University Medical School's Division of Medical Ethics, said it's important to understand that the child, in conjunction with his or her parents, is seeking treatment in these cases.
The doctor's role, he explained, is to ensure the child is psychologically stable and making the decision voluntarily — that it's entirely the child's choice.
"What you're really looking at is authenticity. Is this something new the child has been expressing or have they been asking for a long time," Caplan said, adding, "remember, it's (blocking hormones) reversible. If it's decided to stop the treatment, puberty will resume."
Michele Angello, a Wayne, Delaware County, psychologist specializing in transgender clients, said, "there's been a drastic paradigm shift in parental relationships with their children."
In the past, parents wanted to know how to "fix their (transgender) child," she said. But now, parents ask "how can we make sense of this so we can support our child?"
Angello works with parents to assess the child's "degree of insistence" that he or she isn't the sex the body indicates and determine if it's "just a phase." Phases typically don't last more than six months, she said.
Using drugs to block puberty for transgender kids is fairly new in the United States, where the medication was first prescribed by the Boston Children's Hospital's Gender Management Service in 2007. The Endocrine Society, the oldest and largest organization devoted to research on hormones and the practice of endocrinology, added them to its guidelines in 2009 — despite the lack of FDA approval for this use.
The society recommends treating transgender children, who have been recommended for such treatment by a mental health professional, with hormone blockers at around 10 or 11 years old for a girl and 11 or 12 years old for a boy. At 16 or older, cross-sex hormones can be used to help the teen begin to develop into the gender with which he or she identifies. The society's guidelines on hormone treatment for transgender individuals is being updated, in part, because of how quickly this branch of medicine is evolving.
For decades, some doctors have used hormone-blocking drugs to arrest the early onset of puberty — known as precocious puberty — in children who have begun to mature before age 8 or 9. The synthetic versions of the naturally occurring hormones have also long been used to treat endometriosis in women and prostate cancer in men.
"There's 30 years of experience with this class of drugs for precocious puberty," said Spack, of Boston Children's Hospital's Gender Management Service. "It's completely reversible and there's been no untoward effects."
If the blockers are given at about age 10, a child has the opportunity to take some time to "dress as they wish and use the name they want (without the physical developments that puberty bring)," said Dr. Sherman Leis, a plastic and reconstructive surgeon in Bala Cynwyd, Montgomery County. "They develop very nicely; it is great for these kids, it's much easier and better, they don't get abused and mistreated. They develop an agenda where they belong, not one where they don't belong."
However, some question whether enough is known about gender dysphoria and the long-term effects of delaying puberty, as estrogen and testosterone also are factors in brain development and bone density. And, some say, long-term studies are needed to determine the proper dosage, potency and health effects of the extended use of hormones, which many transgender people will take for the rest of their lives.
"(Bone density) was an initial concern (but) the Dutch erased the issue," said Spack, noting that studies in the Netherlands have been going on for years in relation to using puberty blockers to treat precocious puberty and transgender youth. Further, Spack noted, at age 15 or 16, transitioning teens begin taking estrogen and testosterone, which can help rebuild bone density if it has been reduced.
In a 2015 interview with PBS' "Frontline," Dr. Lisa Simons, a pediatrician at Lurie Children's Hospital in Chicago, said, "The bottom line is we don't really know how sex hormones impact any adolescent's brain development. We know there's a lot of brain development between childhood and adulthood, but it's not clear what's behind that."
The National Institutes of Health recently awarded four children's hospitals a total of $5.7 million for a five-year study to evaluate the long-term physiological and psychological effects of hormone blockers and cross-sex hormones for transgender youth. The study began enrolling 280 transgender youth with gender dysphoria last year.
"We are pleased to see transgender medicine taking its place on the national health agenda," Dr. Johanna Olson of Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, said in an interview with staff at the University of California San Francisco.
In 2012, Pediatrics, the official journal of the American Academy of Pediatrics, published a study of children and adolescents with gender dysphoria. The first such study of its kind in the U.S., it included patients referred for medical treatment to Boston's gender management services program.
Among the study's findings: Transgender youths are at a higher risk of substance abuse, suicidal thinking and suicide attempts. The study did not indicate whether the children were supported by family and others in their gender identity. Additional research, the study said, is needed to understand how teenage patients change psychologically when their physical appearance matches the gender they know themselves to be.
In the latest issue of Pediatrics, a study titled "Mental Health of Transgender Children Who are Supported in Their Identities," found positive mental health outcomes for prepubescent children who are allowed to exhibit the gender they identify with (as opposed to their born gender) by changing their names, clothing, pronoun use and hairstyles.
The transgender children, ages 3 to 12, had normal levels of depression and their anxiety levels were only slightly above their peers, according to the study.
"While previous research has shown that gender nonconforming youth often have elevated rates of depression and anxiety, this study suggests that familial support can be associated with good mental health outcomes in transgender children," the American Academy of Pediatrics said in a statement about the new study.
Spack and some others in the field of pediatric endocrinology said the use of hormone blockers to prevent puberty in boys and girls who say they're in the wrong body is an opportunity to spare them tremendous suffering and possible death by suicide.
"You can't have a meaningful conversation about the fertility effects of such treatment with a 10-year-old girl or a 12-year-old boy," Spack said in a 2013 TED talk. "So, this buys time in the diagnostic process for four or five years, so that they can work it out. They can have more and more testing, they can live without feeling their bodies are running away from them."
For those questioning the ethics of blocking puberty, a study conducted by Dr. Simona Giordano, director of medical ethics for the University of Manchester School of Law in England, examined the issue in "Should We Suspend the Puberty of Children with Gender Identity Disorder?"
"After an extensive review of the literature," Girordano wrote, "(the) suppression of puberty should be offered when the long-term consequences of delaying treatment are likely to be worse than the likely long-term consequences of treatment."
Giordano's research said it was difficult, if not impossible, ethically, to be specific about when hormone blockers should be used because children have different experiences at different times. "Hence, the individual nature of readiness for a decision of this kind makes the psycho-therapeutic element all the more important," she stated in the study.
Spack and Leis are among the pediatric specialists who agree that thorough and ongoing counseling is important for transgender children and their families who are considering puberty-blocking medications.
In his professional experience, Spack said, one of 300 transgender youth changed his mind about which sex he was meant to be. "Puberty can always be resumed," Spack reiterated, just by stopping treatment.
Sophie Lynne, 49, a transgender woman who speaks at Philadelphia area colleges and universities on transgender issues, calls her generation "transgender dinosaurs."
"With hormone blockers used earlier," she said, "the next generation won't have to grow up like us."
Information from: The Intelligencer, http://www.theintell.com