US - Q&A: Doctors on Puberty-Delaying Treatments...

May08, 2008

CHILDREN'S HEALTH

Q&A: Doctors on Puberty-Delaying Treatments

by Alix Spiegel

NPR.org, May 8, 2008 · A small group of doctors around the world have 

introduced a controversial approach to the treatment of preteens and 

teenagers who believe they are the opposite sex.

Right before puberty begins, they prescribe children hormone-blocking 

medication. This allows the child to continue growing without 

developing physical characteristics such as breasts, facial hair or 

Adam's apples. Later, the child can elect to resume their natural 

puberty development or can begin a gender transition by taking the sex 

hormones of the opposite sex.

Researchers in the Netherlands pioneered this treatment. Its 

prevalence in the United States is unclear, because most physicians 

using this approach keep it secretive. NPR talked with two doctors 

about the treatment's benefits and risks: one who practices it in the 

United States and another from the United Kingdom, where the treatment 

is not practiced by the National Health Service.

Dr. Norman Spack

Spack is an endocrinologist at Children's Hospital in Boston. He has 

worked with transgender adults for over 20 years and was one of the 

first doctors in the country to offer hormone-blocking treatments to 

teens.

How many patients do you have on this treatment?

About 10 people are now on the treatment, but we hear from one or two 

new people a week for some kind of service.

How confident are you that you can identify a kid who will become a 

transgender person as an adult?

It's a very good question. My confidence comes partly because I've yet 

to see one change their mind and partly because we're using the 

psychological testing methods the Dutch have perfected, and they've 

yet to see one person change their mind. And they've run 100 kids 

through the treatment.

What physically happens to a child who undergoes treatment?

Ultimately, in a girl it blocks her ability to make estrogen. That 

means her breasts will not grow. The uterus lining will not get built 

up enough to ever flow, and because growth plates stay open, it allows 

a girl to grow for four more years. So genetic females have potential 

to get height [closer to a male height].

For boys, it prevents body hair, facial hair, Adam's apple. And 

remember, hair, along with aspects of the skeleton, can never be 

reversed. If a person goes all the way through puberty and develops 

facial hair, [he or she] will spend, on average, $120,000 in their 

lifetime on electrolysis.

How long do you use the hormone blockers to suppress puberty?

Until around 16. Then you use the cross hormones to bring on the 

characteristics of the opposite sex. And remember, if you just stop 

the hormone blockers at 16, the person will go right back to genetic 

puberty within months. So the beauty of the suppressant is not as a 

treatment but for prolonging the evaluation phase ... 'til a young 

person has greater ability for abstract reasoning. It buys you time 

without a tremendous fear of their body getting out of control.

And the treatment can really enable them to look like a person of the 

opposite sex?

Well, that's what the Dutch have shown. It's quite amazing.

Talk to me about how transgender kids experience puberty.

In the cases of people we see, they are horrified. It's a very risky 

time; many attempt self harm. The development of the first period in 

someone who thinks they're a boy — you can only imagine.

So do groups say you should not do this treatment?

There's been very little criticism. If anything, it's been totally 

opposite to what I expected. Transgender people have written in 

saying, 'Thank God for you. Now another generation won't have to 

suffer.'

[Transgender people are] a group of people who historically have been 

among the most unhappy in the world — and in some cases the most 

poorly accepted. Now I think we can make them happy, and the Dutch 

have shown that they can fit in — in the way they want to. And I think 

we owe it to them.

Dr. Polly Carmichael

Carmichael is a psychologist at the Portman Clinic in London, where 

national guidelines say hormonal treatment of transgender teenagers 

should take place only after puberty. Carmichael has worked with 

dozens of kids with gender identity issues. In 2000, the Portman 

Clinic, which specializes in gender issues, published a study of all 

the children treated at the clinic who had been diagnosed with gender 

identity disorders. There were 124 children in all.

I understand that you have done a study of all 124 children who have 

gone through your clinic, and that 80 percent of those under 12 chose 

not to pursue sexual reassignment as adults. The kids who didn't 

continue — what were their reasons?

It's very tempting to be looking for similarities that might predict 

it, but there's a very wide range. I can think of one [boy] who came 

first at 6 or 7 and we saw on a regular basis. And over that time, he 

felt more comfortable being the sort of boy he was: having female 

friends, being very theatrical. At first, he really wanted to wear 

pink — and the mother was torn between wanting her child to choose his 

own clothes and the teasing. That changed, and at a later stage he 

said he just felt OK as he was — that he still sometimes had those 

feelings, but he felt happy being a boy. And that's how he wanted to 

continue.

I wouldn't say it's impossible to identify individuals [who] will go 

ahead with sex reassignment. Clearly, the Dutch have an assessment 

battery that they feel is quite accurate at identifying them at an 

earlier stage. But I think there's a lot of flexibility.

Do you have reservations about identifying kids under 12 as transgender?

I think some of the children under 12, as well as over, would fulfill 

diagnostic criteria for transgenderism. But I would say, in general, 

my experience is that in younger age groups there is greater 

flexibility, and the figures support that.

How do you feel about giving hormone treatments to young transgender 

individuals?

There are debates to be had around the impact of giving hormone 

blockers at an early stage. One of the debates is, indeed, does one's 

own sex hormones have an impact on identity development in 

adolescence? So if one intervenes, is that affecting the final 

outcome? I think that's just one part of the debate, but important to 

debate.

What we're doing now is new, so it's appropriate to be exploring and 

discussing. And it's a plausible question — is one of the effects a 

change in final outcome?

There's not evidence, though. It's just a question?

I don't know where you'd get that evidence from, really. It's 

relatively new treatment, so in general individuals have been exposed 

to their own sex hormones — and some will go on to be transgender, 

some not. It's more important to have a debate.

Have you been around transgender children going through puberty?

I have been around them, kids up to 16 to 18. It's exceedingly 

distressing for many of them. If you have a strong conviction that you 

are in the wrong body, then to feel your body developing in an alien 

way is extremely distressing. Often, what individuals seek to do is 

avoid any contact or thought of their sexual characteristics. For 

instance, girls bind their breasts in part because they're presenting 

as male outside, but also because they just don't want to see 

themselves. And for adolescent boys, they wouldn't want to look at 

their penis, they would find that incredibly distressing and would wee 

sitting down or would always shower wearing underpants.

When you see that, does it seem cruel to not allow children to have 

hormonal therapy?

It's a really hard question. Obviously, in working with families, one 

is trying to ameliorate distress. It's important to remember these are 

very complex cases; gender disorder is part of a complex presentation.

Why haven't Netherlands researchers had any kids who decided 

transitioning was a mistake?

Because I think they've selected that group. They identify individuals 

through a battery, a group who they feel would go on and seek sex 

reassignment. So it's very positive. But they're a selected group. One 

of the Dutch criteria is a stable biological background, and certainly 

many of the children we see wouldn't fulfill that criterion in that 

they're not psychologically stable.

Is it immoral to give 10-year-olds hormone blockers?

My personal view is no, I don't think it's immoral, but my personal 

view isn't relevant, really. The arguments are complex, and what's not 

helpful is to have a very polarized debate, because that's not the 

issue. It creates a lot of distress among gender identity-disordered 

individuals who feel strongly that they want treatment. But it's 

important to have a proper debate.

The tragedy is we all want the same thing: We want to do our very best 

to support individuals to do what's right for them in the long term 

and short term. The problem is, managing anxiety in the short term is 

very difficult. Suddenly something comes along and offers a solution, 

and I know families have gone to America to seek treatment. It's 

horrible to be cast as withholding something that's the solution to 

everything. But we have to keep the bigger picture in mind, think long 

term, and develop an approach based on evidence.

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Answers edited for content and clarity.

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