Transgender medical treatment for children and adolescents is under attack in many states, labeled child abuse and subject to criminalization restrictions. But it has been available in the United States for more than a decade and is endorsed by major medical associations.
According to a recent review in the British Psych Bulletin, many clinics use treatment plans introduced in Amsterdam 30 years ago. The review noted that since 2005, the number of youth referred to gender clinics in the US, UK, Canada and Finland has increased tenfold.
The World Professional Association for Transgender Health, a professional and educational organization, and the Endocrine Society, which represents specialists who treat hormone conditions, both have guidelines for such treatment. Here’s a look at what’s usually included.
Children who continually question the gender they were assigned at birth are often referred to specialized clinics that provide gender-affirming care. Such care typically begins with a psychological evaluation to determine whether children have “gender dysphoria,” or distress when gender identities do not match a person’s specified gender.
Children who meet clinical guidelines are first given medication that temporarily blocks puberty. This treatment is designed for young people with gender dysphoria who have been counseled with their families and are mature enough to understand what the diet consists of.
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The drug is not started until the child shows the early signs of puberty – enlargement of the breasts or testicles. It usually occurs between the ages of 8 and 13 for girls and a year or two later for boys.
The drugs, known as GnRH agonists, block the brain from releasing key hormones involved in sexual maturation. They have been used for decades to treat precocious puberty, an uncommon medical condition that causes puberty to start abnormally early.
The drugs may be given as injections every few months or as hand implants lasting a year or two. Their effects are reversible – puberty and sexual development resume as soon as the drugs are stopped.
Some babies live on them for many years. One possible side effect: They can cause a decrease in bone density that is reversed when the drugs are stopped.
After puberty inhibitors, children can either go through puberty while they still identify as the opposite sex or begin treatment to make their bodies more closely resemble their gender identity.
For those choosing the second option, the guidelines say the next step is taking manufactured versions of estrogen or testosterone — hormones that induce sexual development at puberty. Estrogen comes in skin patches and pills. Testosterone treatment usually involves weekly injections.
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Guidelines recommend starting these when children are mature enough to make informed medical decisions. This usually happens around age 16, and requires parental consent, said Dr. Gina Sequiera, co-director of the Gender Clinic at Seattle Children’s Hospital.
Many transgender patients take hormones for life, although some changes persist when the drug is stopped.
Dr. Stephanie Roberts, a specialist in Boston Children’s Hospitals Gender Management Service, said that when girls transition from boys to boys, testosterone usually leads to permanent voice loss, facial hair and protrusion of the Adam’s apple. Roberts said that for boys transitioning to girls, estrogen-induced breast development is usually permanent.
Research on long-term hormone use in transgender adults has found potential health risks, including blood clots and changes in cholesterol.
Sex change surgery in teens is less common than hormone treatment, but many centers are hesitant to give exact numbers.
The guidelines say that such surgeries should generally be reserved for people who are 18 years of age and older. The World Professional Association for Transgender Health says breast removal surgery is fine for people under the age of 18 who have been on testosterone for at least a year. The Endocrine Society says there isn’t enough evidence to recommend a specific age range for that operation.
Studies have shown that some children and adolescents resort to self-mutilation to try to change their anatomy. And research has shown that transgender youth and adults are more prone to stress, depression, and suicidal behavior when forced to live as the gender assigned at birth.
Opponents of youth transgender medical treatment say there is no convincing evidence of purported benefits and cite widely discredited research to claim that most untreated children outgrow their transgender identity into their teens or later. One study frequented by opponents included several children who were mistakenly identified as having gender dysphoria and lacked outcome data for many others.
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Doctors say accurately diagnosed children whose transgender identity persists into puberty usually don’t outgrow it. And the guidelines say that treatment should not begin before puberty begins.
Several studies show that treatment can improve children’s well-being, including reducing depression and suicidal behavior. The strongest type of study – a trial in which treatment will be given to some distressed children and not others – cannot be done ethically. Long-term studies on treatment outcomes are ongoing.