Over the weekend, a Colorado transgender girl, Coy Mathis, six years old, won the right to use the female bathrooms at her elementary school. The decision was made by the Colorado Civil Rights Division on Sunday that the Fountain-Fort Carson School District. By not allowing Coy to use the girls' restroom, the Eagleside Elementary School in Fountain 'creates an environment rife with harassment,' Steven Chavez, the division director, wrote in the decision. Coy Mathis, who was being home-schooled pending the decision, will now return to school.

Transgenderism is known within the medical community as gender identity disorder (GID), or gender dysphoria. Although it may be more frequently discussed today, GID remains poorly understood from a clinical standpoint. Awareness of the condition appears to be increasing because of this greater social visibility and presumably social acceptance. Anecdotally, it seems more gender variant children are coming out to their parents and doing so at a younger age. Yet, when a four year old claims he is a girl or she is a boy, one naturally wonders if this child is genuinely gender variant? Children, after all, say and do many things when very young that they naturally drop at an older age.

True or Temporary Identity?

According to the Primary Care Protocol for Transgender Patient Care created by the University of California, San Francisco (UCSF), the most common question asked by parents as well as providers is whether or not this is 'just a phase' of a transgender child. "What the limited research shows: most gender variant natal boys will go on to be gay adolescents and adults, and unpublished data reveals 50 percent of gender variant natal girls will go on to become transgender adolescent and adult men," the report says. In other words, these very young gender variant children may very well be 'going through a phase,' as many parents and medical practitioners suspect.

Within its clinical practice guidelines for the treatment of transsexual persons, the Endocrine Society suggests that for most children with GID, the condition will not persist into adolescence. Acknowledging that percentages differ between studies, the society maintains that "the large majority (75-80%) of prepubertal children with a diagnosis of GID in childhood do not turn out to be transsexual in adolescence." The society further elaborates its opinion on the matter: "Clinical experience suggests that GID can be reliably assessed only after the first signs of puberty."

Concurring on this matter, UCSF states that the small amount of data collected "supports the notion that gender constancy is certainly in place in adolescence." They find that adolescents who present with a transgender identity go on to be transgender adults "100 percent of the time."

If you accept these opinions, how should a transgender adolescent be treated from a medical perspective?

Treatment

The Centers for Disease Control and Prevention reports that lesbian, gay, bisexual and transgender youth (LGBT) are at increased risk for suicidal thoughts and behaviors, suicide attempts, and suicide. Medical practitioners report that patients who have been 'passing' as the opposite sex find puberty intolerable as they begin to take on the secondary sex characteristics — deepening voices and the appearance of beards in boys, development of breasts in girls — and this prevents them from continuing the gender identity they find comfortable. It is time of great psychological stress, with the added possibility of being mistreated by others.

Today, though, medical interventions exist in the form of puberty-suppressing medication; a gonadotropin-releasing hormone (GnRH) analogue will block the GnRH receptor in the brain, and this in turn prevents the secretion of endogenous sex hormones (testosterone and estrogen). Stopping puberty, advocates argue, provides psychological relief to a transgender child; any hormonal changes are fully reversible — once the medication is stopped, puberty progresses as usual — so the medication simply provides an adolescent more time to explore their identity as well as any desire they may have for gender reassignment. In fact, treatment with GnRH analogues makes certain forms of transsexual surgery either redundant or less invasive because many irreversible features (such as height) or surgically reversible features (such as breast and genital development) would not have formed. After passing through adolescence, a trans person may decide to change his or her sex and can begin cross-sex hormones and later, as transgender adults, they will have fewer problems in passing in the new gender than untreated adolescents.

For these reasons, then, the Endocrinology Society recommends "that adolescents who fulfill eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development." 

Medications

One medication prescribed to transgendered adolescents is Lupron Depot or Leuprolide Acetate, which is used to treat a diversity of conditions, including endometriosis, prostate cancer, and 'central precocious puberty,' when children begin puberty too soon (for girls under eight years of age and for boys, under nine). The drug is also being tested for use with patients who have Alzheimer's disease. According to Takeda Abbott Pharmaceuticals, which manufactures the drug, the most common side effects are pain, acne, injection site reactions, rash, vaginitis/vaginal bleeding/vaginal discharge, increased weight, altered mood, headache, fluctuating emotions, and hot flushes/sweating.

"I'm a firm believer in their value," says Stephen Rosenthal, M.D. and Medical Director of the Child and Adolescent Gender Center. "Those that meet the mental health criteria for gender dysphoria in adolescence are likely to be transgender for life. Plus, we have been using this drug for around 30 years for other purposes and its effects are 100 percent reversible if patients change their minds."

The drug is only FDA-approved to treat endometriosis, prostate cancer, central precocious puberty, and fibroids. The use of the drug to suppress puberty in physically healthy adolescents, as is the case with transgender persons, is considered "off-label." "Use of off-label drugs is common practice," says Dr. Rosenthal. "Doctors do so all the time for all sorts of conditions, including diabetes."

Yet some argue that the physical long-term effects of puberty suppression remain unknown. And this is why some people claim that puberty suppression may not only be inappropriate but potentially abusive. "Puberty does not just change the sexual organs; it also affects brain development, bone and muscle development," wrote Dale O'Leary in an article for MercatorNet. "No one knows all the potential side effects of administering puberty-delaying hormones on children; it constitutes human experimentation."

Some simply question whether an adolescent child is able to give truly informed consent. Others argue that allowing adolescents to suspend their normal puberty development is pushing them along the path of sexual reassignment surgery (SRS), which they will feel compelled to undergo after blocking puberty. One other bioethical argument can be made that GID is a hugely complex condition about which too little is understood. In one instance, a man suffering GID and awaiting SRS was administered female hormones for a number of years, which caused enlargement of his breasts and atrophy of his genitals. After being correctly diagnosed with schizophrenia and medicated properly, he regretted the hormone treatment as he no longer believed he was truly female.

Administering puberty suppression medication, then, is a fraught issue that must be carefully considered by transgender adolescents, their parents, and their doctors. Perhaps more public discussion is needed.

 

Sources: Cohen-Kettenis PG, Schagen SEE, Steensma TD, de Vries ALC, Delemarre-van de Waal HA. Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up. Archives of Sexuals Behavior. 2011.

Wierckx K, Mueller, S, Weyers S, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. Journal of Sexual Medicine. 2012.

Fitzgibbons RP, Sutton PM, O'Leary D. The Psychopathology of "Sex Reassignment" Surgery: Assessing Its Medical, Psychological, and Ethical Appropriateness. The National Catholic Bioethics Quarterly. 2009.