Transgender adults largely report satisfaction after they make their transitions. As such, many physicians are comfortable supporting psychologically fit adults who embark on this life-changing journey. When it comes to treating children, however, the real debate begins. There are those who believe that youths who struggle with gender identity should have their feelings affirmed without question and given treatment options from a very young age. On the other side of the argument are those whose concern stems from the fact that children are not capable (and should not be given) the responsibility of making such life-impacting decisions before they have achieved cognitive maturity. Unfortunately, the science on both sides is minimal, which means that each of the camps are populated with activists, health care professionals, well-meaning parents, and most importantly, the children who wrestle with this issue.
Cornell University recently conducted a review of all peer-reviewed articles (fifty-six) published between 1991 and 2017 that address the issue of transgender well-being after transition. They discovered that ninety-three percent of the studies concluded that making the transition improved overall well-being, and that only four of the studies had mixed or null findings. These positive outcomes confirm what nearly all people who transition experience, but most of the irreversible medical interventions are performed only on adults. How children who experience gender identity issues should be dealt with is a hotly debated topic in both the medical and trans communities.
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Billie Lee grew up in a small town with no exposure to transgender people, but as a child, she knew innately that her anatomy was at odds with how she identified gender-wise. Without any reference or knowledge that the trans community even existed, she struggled with her identity daily. In an attempt to fit in, she tried to embrace her masculinity, but despite her best efforts, she could not suppress the “feminine essence” that was integral to her personality. Her attraction to boys, which was regarded as unacceptable, and her confusion over the discrepancy between her mind and body resulted in bouts of depression, anger, sadness and suicidal thoughts. As a middle-schooler, she engaged in flirtatious behavior with boys who reciprocated, but not because they were gay – it was because they were attracted to her more feminine, nurturing side. Having nowhere to turn and no language to describe her predicament led to a steep increase in her anxiety and mental distress.
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The controversy over how to deal with children who experience gender identity issues is largely due to the argument over suppression of puberty. Though reversible up to a certain point, there are ethical, biological and psychological concerns that must be studied further before any definitive answers are reached. This dearth of science, however, doesn’t prevent the expression of very strong opinions on the subject. Some feel that a child should be able to access these powerful drugs as soon as possible, while others feel that administering them at such a tender age is tantamount to child abuse. Predictably, there are a wide variety of opinions that fill out the spectrum in-between.
Pubertal suppression entails deferring the onset of secondary sex characteristics, which includes development of breast tissue and widening of the hips for women and the appearance of an Adam’s apple and facial hair for men. It also triggers the growth of pubic and underarm hair, affects stature and gives rise to maturation of the sex organs. Puberty occurs when the pituitary gland sends signaling hormones to your ovaries or testes so they can begin production of testosterone or estrogen. Suppression of puberty is usually achieved by the use of puberty blockers called gonadotropin releasing hormone agonists (GnRHAs). These drugs block the release of follicle stimulating hormone (FSH) and luteinzing hormone (LH) from the pituitary gland. This effectively prevents the secretion of estrogen and testosterone from the gonads, and halts puberty and the development of the previously mentioned secondary sex characteristics. These cannot be reversed after puberty occurs.
Proponents of puberty suppression offer several arguments to bolster their claims that it should be an option available to children. Chief among these is that (up to a point) this therapy is reversible and gives children more time to fully explore questions related to gender identity before having to make a decision. According to the World Professional Association of Transgender Health, physicians may recommend suspension of puberty in gender non-conforming youth who have undergone a psychiatric assessment and have reached a Tanner Stage 2 of puberty – when it is felt that the child has some experience of gender. People in favor of offering these drugs argue that there are minimal side effects, and that the drugs can be stopped in order to reactivate puberty if the patient decides to discontinue with the process. They argue that providing a child with the opportunity to avoid development of male and female characteristics can lay the groundwork for a much smoother and easier transition; he or she may be able to avoid certain surgeries as well as financial hardship and emotional distress. Arguments about irreversible sterility are countered with the promise of harvesting eggs or sperm to be used at a later date.
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Adolescence is a challenging time for anyone and it was particularly so for Billie. Having no vocabulary to describe her plight, let alone any effective guidance or answers about what she was experiencing internally, she entered puberty, which she describes as traumatizing. This period is trying for most young people. Rapidly changing bodies can trigger a broad range of emotions, including confusion associated with gender identity. Though most come through the experience relatively unscathed, there is a population for whom this issue remains unreconciled.
Billie tried to “surrender to becoming a boy,” and accept her fate, even as she felt she was “becoming a monster physically.” Extremely shy, and known as the one “who cried all the way through high school,” Billie became an alcoholic during this period and frequently blacked out in order to cope with her ordeal. Her depression was omnipresent as her body continued to betray her. Not only was she dealing with her burgeoning maleness, but she was still concealing the fact that she had more than the average amount of breast tissue. Her suicidal ideation became intensified every time she tried to accept being male, and her friends are what stood between her and any attempt to follow through with it.
Having completed puberty and dealt with the challenges it presented, Billie wishes that she had been given the option to take puberty blockers at a young age. She feels that she would have avoided an immense amount of the heartache, saved a lot of money and been able to “be who she was” much earlier in life.
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Many transgender people describe journeys similar to Billie’s, but the medical community is divided about how to deal with them. Some physicians who treat transgender people believe in offering the hormones, while a larger contingent suggests exercising caution when it comes to puberty suppression. In addition to potential long-term effects on bone density, brain development and the heart, doctors who are reluctant to support pubertal suppression say that we simply don’t know enough to make such a consequential decision for a child.
Gender identity typically develops in early childhood, but can be dynamic, evolving well into adolescence and even adulthood. Moreover, eighty to ninety-five percent of youth who struggle with gender identity emerge from the experience physically and psychologically intact after going through puberty without affirmation of the gender that is experienced. This is strong evidence to support the notion that, if left untreated, these issues largely resolve themselves. Opponents are also concerned that arresting a normally developing body might prevent a child from experiencing any certainty in one direction or the other.
A study done in the Netherlands and published in 2011, followed up on seventy boys who underwent pubertal suppression and found that all of the subjects went on to take cross-sex hormones. In her 2016 article in Journal of American Physicians and Surgeons, Dr. Michelle A. Cretella, a board certified pediatrician and president of the American College of Pediatricians, cites this as cause for alarm due to what appears to be a self-fulfilling prophecy created upon taking the initial hormone blockers. She warns about the danger of encouraging a boy (whose brain is still plastic) to live as a girl, because puberty suppressing hormones, combined with this behavior can alter the structure and function of the brain, potentially reinforcing something that might have turned out differently without the affirming behavior. She points out that making the move from puberty blockers to cross-sex hormones will eventually result in sterility, can cause psychosocial isolation and (in the case of males) result in a person who doesn’t necessarily identify as male or female, but non-male.
This faction of the medical community often refers to the oath they took to “first do no harm.” They are deeply concerned about the trend to quickly diagnose and affirm a young person as transgender because the majority of these cases will resolve themselves without treatment. They worry that making such a life-altering decision for a child may come at the cost of future regret, sterility and long-term health problems that are currently unknown. There is simply no rigorous scientific evidence that gender identity issues are an innate trait. That being said, doctors are supposed to improve the lives and outcomes for patients independent of these concerns. Clearly, these treatments are appropriate for some people, but currently, there is no standard protocol when it comes to selecting who should receive the treatments let alone which treatment is correct for that person.
Some studies overwhelmingly confirm that people who transition experience a quality of life and happiness levels on par with the general population. The World Professional Association for Transgender Health says that there are risks of withholding medical treatment for adolescents. They say that gender dysphoria may be prolonged and “contribute to an appearance that could provoke abuse and stigmatization. They also point out that “gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence,” and so, “withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.” They also say that, “before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken.”
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Unsurprisingly, physicians’ opinions run the gamut on this issue. On one side of the argument is Dr. Simona Giordano, a Reader in Bioethics at the School of Law, University of Manchester. Her opinion is that, “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.” On the other end are physicians like Michelle A. Cretella who asserts that, “a person’s belief that he is something or someone he is not is, at best, a sign of confused thinking; at worst, it is a delusion. Just because a person thinks or feels something does not make it so.”
The argument about what is ethical treatment for children confronting this issue will likely rage on until more reliable data is collected. Meanwhile, people like Billie Lee must navigate gender identity challenges as best they can, given the limited information that is available.
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