gender dysphoria, & gender identity
Using medication to delay
puberty in transgender teens
As noted elsewhere in this section a transgender
individual is frequently defined as a
person who experiences Gender Identity Disorder (a.k.a. Gender Dysphoria), Their
genetic gender -- as evidenced by their sex chromosomes and generally by
their genitals -- is different
from their perceived gender. Some describe themselves as a woman trapped in a man's body,
or vice versa. Others view themselves as having a male brain in a female body,
or vice versa. Still others describe their feelings with other explinations.
The International Endocrine Society (IES) 1 issued a
draft set of guidelines in early 2008-DEC. 2 They are
co-sponsored by the European Society of Endocrinology
(ESE), The World Professional Association for Transgender Health (WPATH),
and Lawson Wilkins Pediatric Endocrine Society (LWPES).
The guidelines recommend that some transgender children as young as 12
years-of-age should be given medication to suppress puberty. This would greatly
simplify gender reassignment surgery if they decide to undergo it later in
life when they have sufficient maturity to decide this.
The main benefit from such puberty blockers would be the avoidance of the inevitable
body changes caused by puberty. For example, a male-to-female (MTF) transexual
could avoid having her voice deepen, a masculine bone structure appear, her Adam's
Apple enlarge, and hair growth on her face. A female-to-male (FTM)
could avoid developing breasts, feminine shaped hips, and female bone structure
elsewhere. Without these bodily changes, there would be less to change during
gender reassignment surgery (GRS).
Another benefit of
putting off puberty would be that the individual would be more mature and capable
of making a settled decision in their mid-teens rather than their pre-teens. If,
at the age of 16 or so, they decide to not proceed with gender reassignment surgery, they can simply stop the puberty blocker medication and go
Changes at puberty are normal, natural, and anticipated to the over 99% of youths who are
cisgendered -- i.e. whose genetic gender matches their perceived gender. But they
can be terrifying and repulsive to a transgender person. The latter are prone
to depression, self-harm, suicidal ideation, attempted suicide, and, sadly, completed suicide. There is a
phrase -- the 50% Rule -- used by many transgender and transexual
individuals. It refers to the common belief that 50% of all untreated
transsexuals die before the age of 30, usually by suicide.
By preventing puberty from occurring naturally, various physical changes would not have
to be corrected by surgery and other procedures. Gender reassignment surgery (GRS)
would probably result in body contours and other features that more accurate
resemble that of the desired sex.
The IES recommendations are largely based on the experience of a clinic in the
Netherlands which has prescribed puberty blockers to over 70 teens under the age
of 16. Henriette Delemarre-van de Waal of Leiden University Medical Center has
been involved in the testing. She said:
"Until now, we don t have any patient who has regretted their decision on
the treatment. ... [Without treatment] they self-harm, they develop an
enormous aversion against their bodies, they isolate themselves, and their
school performance suffers." 6
The mother of one MTF transsexual in London UK described her daughter's
experience. She started to question her male body at the age of 4. She found the
pubertal changes that started at age 12 to be intolerable. She started to harm
herself and threatened several times to cut off her penis. She is now 15 and
wants to start her sexual reassignment when she is 16. Her mother expects her
daughter to still have problems ahead, but said that they would be "increased by
600 percent" if she had gone through normal puberty. The daughter has stated
that "I would rather die than be a man." 6
Peggy Cohen-Kettenis of the Free University of Amsterdam Medical Center said:
"People are always afraid that if will be harmful for the children. But
what they never take into account is that it is also harmful to not
give them this treatment." 6
Some clinics in Australia, Canada, Germany, the U.S., and elsewhere have
started to offer treatment to transgender teens in order to suppress the onset
of puberty. The medication is prohibited by law in the UK.
Text of the draft guidelines:
Section 2 of the draft guidelines deals with the treatment of transgender
adolescents. It states:
|2.1. We recommend that adolescents who fulfill eligibility and readiness
criteria for gender reassignment initially undergo treatment to suppress
|2.2. We recommend that suppression of pubertal hormones start no earlier
than Tanner stages 2-3 3,4 and when girls and boys
exhibit pubertal levels of estradiol and testosterone, respectively.
|2.3. We recommend GnRH analogues be used to achieve suppression of
|2.4. We suggest that pubertal development of the desired, opposite sex be
initiated at about the age of 16 years, using a gradually increasing dose
schedule of cross-sex steroids.
|2.5. We recommend referring hormone-treated adolescents for surgery when:|
- The real life experience 5 has resulted in a
satisfactory social role change,
- The individual is satisfied about the hormonal effects, and
- The individual desires definitive surgical changes.
|2.6 We suggest deferring surgery until the individual is at least 18 years
Potential problems with puberty blockers:
Linda Geddes' article in New Scientist list some concerns with
Some children with transgender feelings appear to grow out of
them by adulthood.
"...few trials have explored the long-term effects of delaying
puberty in this age group." 6
Some teens may not be sufficiently mature to make a responsible
decision concerning puberty blockers when they are about 11 or 12 years of age.
Puberty blockers would prevent transgender teens who are
genetic males from freezing their sperm in order to father children later in
life, should they wish to do this. 6
An editorial in the same magazine noted:
The age of puberty onset is dropping. Some girls aged 9 are
starting the process. An editorial in New Scientist asks: "Does, say, a 9
year-old have the emotional maturity to make a decision of this magnitude?"
These, and perhaps other concerned need to be weighed against
the horrendous loss of life through suicide among transsexuals in their teens
The following information sources were used to prepare and update the above
essay. The hyperlinks are not necessarily still active today.
- The Endocrine Society's home page is at:
- Wylie C. Hembree, et al., "Endocrine Treatment of
Transsexual Persons: An Endocrine Society Clinical Practice Guideline," Draft
version, at: http://www.endo-society.org/
This is a PDF file.
- The Tanner Stages of puberty are numbered from 1 to 5. In girls, they are
qualitative values related to the extent of breast development and pubic hair
growth. In boys, they are values related to early penile and scrotum
enlargement. Stage 2 is reached at about 11 or 12 years-of-age.
- "Puberty and Tanner Stages," Estronaut, (1999), at:
- The Real Life Experience (RLE) referred to in section 2.5.2 is a
generally accepted prerequisite for gender reassignment surgery. A patient must live in their
perceived gender role either as a student, in a volunteer position, or at work.
They must "out" themselves to friends and family and change their name
to reflect their perceived gender.
- Linda Geddes, "Delay puberty in transsexual teens," New Scientist,
2008-DEC-13, Page 8 & 9.
- "Sex, drugs and surgery," New Scientist, 2008-DEC-13, Page 5.
Copyright © 2009 & 2011 by Ontario Consultants on
Original posting: 2009-JAN-08
Latest update: 2011-APR-21
Author: B.A. Robinson