Quick background: This is a follow-on from the post I wrote in response to SkepDoc Harriet Hall’s sadly misleading post Gender Dysphoria in Children. In my reply, I challenged the myth that children with gender dysphoria are being pushed or rushed into transitioning at very young ages. In fact, international medical guidelines on the subject are clear that medical treatment for children with gender dysphoria should not be started prior to puberty (for more on recommended management of younger children with gender dysphoria, see Part One).

I’m writing Part Two because I realised there is a fairly obvious follow-up question that readers might have; while that’s all well and good, why are children starting medical treatment for gender dysphoria during puberty? After all, at this stage they’re still children. Surely, runs this line of argument, it would be better for them to wait until adulthood before any decision is made about medical therapy with its possible (or definite) long-term consequences? It’s an argument that sounds superficially logical and has convinced many people.

Unfortunately, there is a huge problem with it: Children’s bodies are not going to wait. When the decision arises as to whether a pubertal child with gender dysphoria should start medical treatment or not, the alternative to treatment is not going to be that everything remains comfortably in status quo for several more years while the child grows up. The alternative is going to be that the child goes through the significant biological changes that come with puberty.

For a child with persistent gender dysphoria, this is a very big problem. If you read Part One of this, you might remember the Steensma et al research study that looked at the differences between ‘desisters’ and ‘persisters’ with gender dysphoria, and found that the onset of pubertal changes had been a key point for the children they surveyed; while those changes improved the desisters’ feelings of gender dysphoria, they worsened the gender dysphoria symptoms for the persisters. A lot. Children who already felt uncomfortable and out of place with having a body whose gender didn’t match theirs were faced with that body developing much more specific features of that gender… and they found this quite a horrific sensation.

It was terrible, I constantly wanted to know whether I was already in puberty or not. I knew about the puberty blocking treatment and I wanted to be in time. I really did not want to have breasts, I felt like, if they would grow, I would remove them myself. I absolutely did not want them!

I noticed the Adam’s apple of my brother, and an uneasy feeling stole upon me. If I would get an Adam’s apple like his, I did not want to live.

When I was 13, I started to menstruate and my breasts started to grow. I hated it! If we would have had a train station in our town I would definitely have jumped in front of a train. I didn’t go to school anymore, lost my friends and became totally withdrawn.

As soon as puberty started, I could no longer be myself. A boy does not have breasts. As a child it didn’t matter that much, boys and girls don’t differ except that boys have a penis, and girls don’t. But the way I was changing was very wrong. I couldn’t hide it anymore.

At the time my breasts started to grow, I wanted to hide them. I always tried to wear loose shirts. I felt so insecure that I didn’t want other people to see me. So I frequently skipped school and they suspended me. Then I became even more withdrawn.

Before puberty started, I felt physically a boy, but when my breasts started growing, I felt more like a mutant.

(quotes from young people with persistent gender dysphoria in Steensma et al., ‘Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study‘, Clin Child Psychol Psychiatry 2011; 16(4): 499 – 516)

(With regard to the suicidal impulses expressed by some of these patients; yes, this is a very real risk. Several studies have shown a very high rate of suicide attempts among transgender people, and many of these work. Transitioning, and general acceptance and support from others, have both been shown to decrease this risk significantly.)

Imagine, for a minute, that you read or hear a story about doctors at a gender identity clinic forcing a child to go through puberty in the gender that isn’t theirs, against that child’s wishes, even though the child was distressed about it to the point of suicidal unhappiness. We’d all be appalled at the thought. Well… that’s what children with gender dysphoria of this severity go through when made to experience puberty without medical treatment. Their body doesn’t match their gender identity; when they  go through puberty, they’re having to deal with their body becoming more and more obviously that of a gender that isn’t theirs.

As though that wasn’t bad enough, forcing children to endure the wrong puberty has long-term consequences as well; that child is now going forward into adulthood with physical changes that are much harder to reverse. If that child is a transgender girl (a child with the physical body of a boy, but with the internal gender identity of a girl), then she’s had to develop facial hair, stronger facial features, and a deep masculine-sounding voice. She’s going to be stuck with the choice between either having a lot of difficult (and expensive) procedures to reverse these, or spending her life looking and sounding noticeably male even once she starts taking hormone treatment to transition (with all the considerable social stigma and unpleasantness that this will cause her). If that child is a transgender boy who wants to transition physically, his eventual transition will have to include surgery to remove the breasts that could have been prevented from growing in the first place.

There are times in life when doing nothing is a decision. It might be a default decision rather than an active one, but it’s still a decision and it still has consequences. When a persistently transgender child has started puberty, is becoming frantic with the changes, is becoming ever more certain about their decision to transition, is faced with puberty still proceeding apace… then that’s one of those times. In such a situation, doing nothing – withholding medical treatment, insisting that the child has to endure all these changes for years more before being allowed to start treatment for them – is outright harmful to that child.

Of course, it’s also preferable for children not to be making a final decision about transition at that point. After all, we’re talking here about children who are in the early stages of puberty, hence in their early teens at most and in many cases younger than that. Whatever myths you might have heard about gender identity clinics, the professionals there are in fact fully aware that children might change their mind, and are not in any sort of hurry to rush a young child into anything irreversible or even difficult to reverse. So, when a child with persistent gender dysphoria is finding that the early changes of puberty are making the symptoms worse and not better, this presents a dilemma.

Here, therefore, is the management that the WPATH (the international) guidelines advise in such a situation:

When, and only when, a child has persistent and intense symptoms of gender identity issues that are getting worse rather than better with puberty, and other issues in the child’s life have been looked for and dealt with so that this isn’t a case of, say, a child making a poor decision due to severe depression or anxiety, and the child wishes to start treatment after a full discussion of the pros and cons with child and family… then doctors will start a type of treatment known as a puberty blocker. This does not cause any physical gender changes; as the name suggests, it blocks the hormones that cause pubertal changes, thus allowing doctors to hit the ‘pause’ button on the child’s puberty and give them a few extra years to make a decision about gender transition. During this time, the child should be under the care of a paediatric endocrinologist who monitors their response to the puberty blocker and is on the lookout for any side-effects.

If the child’s gender dysphoria persists, and remains at such a level that they wish to physically transition, the next step is hormonal transitioning; taking either testosterone or oestrogen, as the case might be, to bring about the bodily changes of the gender with which the child identifies. (At this point, most people do go on to transition – after all, by this stage you’re down to a subset of transgender children with severe and persistent problems – but it isn’t inevitable. Children who decide against transitioning can simply stop the puberty blockers and allow puberty to proceed normally.) While this is, of course, the point at which changes do start becoming irreversible, that still doesn’t happen straight away. This isn’t like waking up from surgery; the hormonally-induced body changes need to be there for some weeks before they gradually become irreversible, whereas if someone finds that the changes towards a different body are distressing then that reaction is going to be present from an early stage. So, even at this point, we’re still talking about having some leeway to stop things; you haven’t committed irreversibly to gender transition from the moment you swallow your first pill.

The decision about whether or not to transition hormonally is generally taken and implemented around the age of 16, though that’s not an absolute. Again, this is a compromise; the desirability of giving children as much time as feasible to make this decision has to be weighed against the distress of being in a wrong-gender body plus the psychosocial and sometimes physical ramifications of postponing puberty.

As for genital surgery, the guidelines advise that this should be postponed until adulthood. (They also advise waiting until the person has lived as the gender in question for at least twelve months.) It is worth noting here, by the way, that surgery is by no means an inevitable step of transitioning; it’s the one step that everyone who doesn’t know much about transgender treatment will focus on, but in fact many transgender people find that transitioning with the use of hormones is enough for them and that, once the rest of their body matches their inner gender identity, they can deal with having a wrong-gender set of genitals. Either way, it is recommended that this step not be taken prior to adulthood.

Now, hopefully it should be clear by now that the reason for this protocol is that so far it’s the best compromise that exists between the potential risks of treatment and the known risks of not treating an adolescent with severe gender dysphoria who is distressed by pubertal changes. Whatever myths you might have heard, no-one is recommending this because they are oblivious to the potential side-effects of medication or because they think that prescribing for a child is an ideal and sought-after situation. It isn’t. The ideal situation would be for everyone to be born into a body that matches their own inner gender, so that transgender problems wouldn’t exist. For that matter, the ideal situation would be for no child ever to have a condition serious enough to need medication; I don’t know of anyone who wouldn’t be delighted with that situation.

But that, of course, isn’t the situation we’ve got. We have the real world. Some children have serious, or potentially serious, medical conditions which do require treatment; not because medicating children is ideal, but because the consequences of not prescribing for a child with a serious problem can be worse. One such problem is severe gender dysphoria. We can leave children in such a situation to suffer the consequences of an untreated condition – knowing there is a high risk that those consequences will have a serious and significant impact on the child – or we can offer them treatment. It’s hard to believe that any of us would choose the former option were it any other medical condition involved. Why should we do so for children with gender dysphoria?