There is an ongoing, and sadly often ill-informed, discourse around what the ‘appropriate’ age for trans adolescents accessing gender-affirming healthcare should be. The focus should be placed more on the importance of a ‘Stage not Age’ model of care.
The conversation brings up some important questions:
What does such an ‘appropriate’ age even look like?
And who should be the one deciding what the ‘appropriate’ age is?
The Gender Recognition Act 2004 only takes into consideration trans people over 18, dismissing trans children and adolescents almost entirely. In some quarters of the ‘debate’ there is a fear that if young people were to be exposed to the possibility of ‘transitioning’ during childhood or adolescence, some may mistakenly commence treatment which they might later regret. While there are cases of patients pausing or even stopping their gender-affirming treatment, there is little meaningful evidence that this is the case. The majority of peer-reviewed studies reflect extremely low regret rates, yet a negative narrative still persists. It suggests that children are old enough to know that they are cisgender, yet never old enough to know that they are transgender.
Dr. Webberley and GenderGP’s work
Dr. Helen Webberley is a healthcare professional with extensive knowledge and gender-affirming healthcare expertise. She made it her mission to facilitate young trans people’s access to the healthcare support they deserve. From the start, she based her treatments on what was best for each individual patient, providing more patient-centered healthcare provision and taking into account every treatment option. This approach is the one taken forward by GenderGP
‘Stage Not Age’ describes the practice where a patient’s access to gender-related healthcare should not be based solely on their age but should also put an emphasis on the young person's development stage. By focusing on ‘age’ rather than ‘stage’, healthcare professionals run the risk of dismissing their patients’ very individual needs. This could lead to them indiscriminately administering the same treatment to each patient of a certain age – something that GenderGP believes is not in the patient’s best interest.
Dr. Webberley is not the only practitioner who believes that ‘stage-not-age’ is an appropriate Model of Care. Dr Daniel Shumer is a paediatric endocrinologist and founder and clinical director of the Child Adolescent Gender Services Clinic at Mott Children’s Hospital in Michigan. He also deems that it is the ‘pubertal stage of the patient that matters’ and not their age.
In addition, Dr. Johanna Olson-Kennedy, a world-renowned gender specialist, acknowledges the importance of individualised care plans over protocols for trans adolescents being ‘appropriate and critical when working with gender diverse youth’. This is especially evident given the historical oppression and gatekeeping trans and gender-diverse people have experienced within medical care.
The Endocrine Society Guidelines 2017 does not require a patient to be at least 16 years old in order to be eligible for the prescription of gender-affirming hormones. They also recognise that while there are only a few published studies regarding gender-affirming hormone treatments being given to patients under the age of 13, the reasons for initiating this treatment can be compelling.
Dr. Daniel Klink, a paediatric endocrinologist who served as an expert witness for the General Medical Council (GMC), revealed that he had also treated transgender adolescents aged thirteen and fourteen with gender-affirming hormones. Initially, he stated that the use of testosterone is safe when administered to induce cisgender puberty. He added that there was not enough research on testosterone's use to induce trans adolescents’ puberty.
How safe is gender-affirming healthcare for trans adolescents?
Despite GenderGP’s Model of Care and the ‘Stage not Age’ approach becoming increasingly common practice, the argument that young trans people should be restricted in the care and support they receive persists. This is in part due to medical provision for cisgender patients being considered different compared to that provided to transgender patients, often resulting in healthcare professionals being overly cautious when making a decision around young trans people’s treatments.
Nevertheless, Dr. Klink confirmed at Dr. Webberley’s MPTS hearing that in his expert opinion, ‘there are no reasons to suspect that administration of sex steroids to induce puberty in a transgender adolescent would be less safe than the administration of sex steroids to induce puberty in a cisgender adolescent’ (p.47 MPTS), especially given that no significant medical concerns have been reported so far. With Dr. Olson-Kennedy’s study reporting ‘no adverse outcomes’, the hearing also found that there is enough evidence regarding the safety of using testosterone to induce a puberty in transgender men at the age when puberty would normally occur (puberty usually begins around the age of twelve in cis men).
There is nothing to indicate that the use of gender-affirming healthcare for trans youth is any less safe than the administration of hormones to cisgender youth, an area of medical provision that is entirely uncontroversial and is well-studied and evidenced.
Moreover, the increasing safe global use of hormone replacement therapy (HRT) to treat trans adolescents with gender dysphoria or gender incongruence is further vindicating a ‘Stage not Age’ approach. The approach, and the ever-growing body of evidence to support it, have most recently been endorsed by recent changes to WPATH Standards of Care.
We centre the needs and experiences of young patients in almost all other areas of provision; the medical community should work harder to implement the ‘Stage not Age’ framework for trans youths as well.