Over the past thirty years the idea of gender identity has become more prevalent. More people are expressing themselves in relation to new terms and ideas relating to gender. Are these new ideas helpful for someone who perceives their gender as different from their physical body? Have the treatments been helpful? Even more concerning are the potential harmful effects this has on children processing who they are. Should children be affirmed in transitioning into a different gender?
There have been different terms used by psychiatrists but the American Psychiatric Association has settled on Gender Dysphoria which is defined as the involvement of “a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify.” In order for a positive diagnoses of gender dysphoria in children to be found the children must have experienced stress from the dysphoria for at least six months and must show desire for traditional gender type activities such as:
- strong desire to be of the other gender or an insistence that they are the other gender
- strong preference for wearing clothes typical of the opposite gender
- strong preference for cross-gender roles in make-believe play or fantasy play
- strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
- strong preference for playmates of the other gender
- strong rejection of toys, games and activities typical of their assigned gender
- strong dislike of their sexual anatomy
- strong desire for the physical sex characteristics that match their experienced gender
The Dutch Protocol lists Gender Identity Disorder (GID) as the most extreme form of dysphoria. In these extreme cases they use a therapeutic approach that focuses on emotional, behavioral and familial problems that may or may not be the cause for gender dysphoria. This protocol uses the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) that is verified through the American Psychiatric Association.
According to Boston Children’s Hospital, “Gender dysphoria of childhood is not a surgical diagnosis. It is a medical diagnosis that does not require treatment, other than possibly individual or family therapy, until a child reaches puberty.” Through the APA in the US the recommended treatment options for children are counseling, cross-sex hormones and puberty suppression. “Treatment may focus primarily on affirming psychological support, understanding feelings and coping with distress, and giving children a safe space to articulate their feelings.”
Other countries are following the treatment process for The Dutch Protocol which says, “In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years.” There are five phases for treating gender dysphoria through the Dutch Protocol: Social transitioning (“allowing children to adopt the clothes, names, and social identity of the opposite gender”), puberty blockers, cross-sex hormone treatment, surgical remodeling and commitment to a lifetime of upkeep from effects of therapy and surgery. Cross-sex hormone therapy is usually not administered until puberty starts to set in, which averages out to age eleven for girls and twelve for boys. The World Professional Association for Transgender Health (WPATH), based on the Dutch Protocol, recommends waiting until age sixteen to start the hormone therapy but that puberty blockers can start by the age of twelve. There is a transgender health continuing education document on the cross-sex hormone therapy for physicians and psychiatrists that lists various doses, applications and potential risks from the therapy.
Through cancer research it has been found that the Gonadotropin-releasing hormone is “A hormone made by a part of the brain called the hypothalamus. Gonadotropin-releasing hormone causes the pituitary gland in the brain to make and secrete the luteinizing hormone (LH) and follicle-stimulating hormone (FSH).” This hormone is used to block the onset of puberty. The Endocrine Society approved puberty suppressors in 2008 for adolescents from age twelve and on. Doctors at Lurie Children’s Hospital of Chicago say that, “The use of puberty blockers to treat transgender children is what’s considered an “off label” use of the medication — something that hasn’t been approved by the Food and Drug Administration. And doctors say their biggest concern is about how long children stay on the medication, because there isn’t enough research into the effects of stalling puberty at the age when children normally go through it.” During cross-sex hormone therapy the hormones of testosterone, estrogen and ant-androgen are used.
The mental health of 73 socially transitioned patients, aged three to twelve, was assessed by way of a questionnaire answered by their parents. “These results were compared to those from two groups of non-transgender children: 73 of the same gender identity from the same community and 49 siblings of children in the transgender group.” The study showed that family support had a positive impact and anxiety was only slightly elevated about the non-transgender children. It was acknowledged that the long-term mental health was not known and that the parents may assess their child’s mental health more positively. In the International Journal of Social Sciences, fifteen sets of parents were asked to assess their child’s mental health. Again, the assessment was positive. A small sample size and a short social transition time period are limitations of this study. In 2008, a study observed the continuing gender dysphoric tendencies of patients from preadolescent ages to ages just past adolescence, it was found that “43% were no longer gender dysphoric”.
Concern of osteoporosis in transgendered individuals was found from the University of California with small evidence of the GnRH contributing although there is no long term study to go in further depth. In a study of women going through endometriosis and using GnRH, it was found that, “The number of study participants was too small to determine a relation between Bone Mineral Density (BMD) loss and length of ‘GnRH agonist’ treatment or total dose of HRT (Hormonal replacement Therapy)”. Another study observed 34 patients from first treatment of GnRH to age 22 collected over a period of fourteen years. The BMD was lower than what had been the factored pretreatment potential. This is not enough to concern the physicians though. One more study showed that patients who continued to have gender dysphoria into adolescence would take GnRH, and of the 70 studied, all continued to the next phase of cross-sex hormone therapy. It is possible that GnRH could affect fertility negatively although most studies are for increasing a deficiency of GnRH to help fertility.
The effect of cross sex hormone therapy on fertility was researched by The Journal of Pediatrics. An accurate assessment could not be formulated due to a small number of studies relating to the subject with conflicting information. The most well known information came from hormone treatment on hormonal diseases and those effects. They conclude that more long term studies will need to be done to determine hormone therapy effects on gametes. An article written by John Whitehall, a Professor of Paediatrics at Western Sydney University, explores the data from four different studies which separately show that not enough studies were done to provide accurate information concerning how to best treat gender dysphoria, that mental disorders are common in those diagnosed with gender dysphoria, little was done to observe the possible mental disorders and that often there were issues with family relationships.
A journal written by BMJ EBM Spotlight, concluded that “There are significant problems with how the evidence for Gender-affirming cross-sex hormone has been collected and analysed that prevents definitive conclusions to be drawn.” Dr. Frederic Ettner, a physician who has worked with transgender patients for over two decades said, “what are the benefits and adverse effects of starting young kids on these powerful [puberty blockers] and then hormones? We don’t know, since hormone treatment began for transgender youth, there’s been a paucity of data on what happens to them in the long term.” In the end, perhaps the biggest danger for children is that these treatments are being done knowing that the possibility of great physical and mental harm could happen and that further testing needs to be done.