Hormonal manipulation for children and young people broadly comes under two headings:
These can be introduced early on in the child’s development in order to pause the onset of puberty and prevent the ‘wrong’ secondary sex characteristics from developing.
Gender affirming hormones
These enable the child’s puberty to progress in line with their gender identity.
Puberty blockers – Gonadotrophin releasing hormone (GnRH) agonists – are a type of medication which temporarily stops the production of the natural sex hormones that progress puberty. They are an injection given every three months and are simple, safe and effective.
If a child entering puberty continues to present with true feelings of gender variance that have been there from an early age and have not gone away, it is highly unlikely that this will be a ‘passing phase’. If the feelings are strong and always have been, if the child hasn’t wavered from the knowledge that their true gender does not match the one that most commonly fits their biological sex, if their unfaltering aim is to live in the role of the gender with which they identify, rather than the one by which they are classified as a result of their genitals: then these hormone blockers can literally be lifesaving.
The most important thing for young people, in whom long-standing gender variance is identified, is to offer to support them by delaying the secondary sex characteristics from developing: stopping the testes producing testosterone, or the ovaries producing oestrogen.
Puberty blockers should only ever be given to young patients after a thorough assessment of their medical and psychological needs has been carried out. This medication should never be given to a child unless it is believed that the child is suffering from true gender variance and their wellbeing is at risk. It should be prescribed with the full support of the child’s next of kin and wider support network. Puberty blockers are best started in line with the onset of puberty, they are not to be used to prevent puberty from initiating.
Gender affirming hormones
Gender affirming hormones refers to the prescribing of the female hormone, oestrogen, to a trans female or the male hormone, testosterone, to a trans male, enabling the body to develop the secondary sex characteristics in line with the patient’s true gender, rather than the gender they were assigned at birth.
Prescribing these hormones has potentially long-lasting and irreversible implications, and as such no doctor would ever choose to actively prescribe such medication unless it was in the best interest of the patient.
But where is the evidence that gender affirming hormones work? How do we know the long-term implications?
The reality is that there is very little scientific evidence and clinical experience on which to base medical decisions relating to the best treatment plan for transgender patients. This is because, until now, many transgender patients have remained hidden from view for fear of repercussions. As such there has never been a large enough sample size on which to base such research. Of course, there are also ethical dilemmas when proposing such a study in which treatment might be given to one child while being withheld from another in order to provide a comparison.
But, fortunately things are starting to change.
Just last week Australia published the world’s first guidelines on the treatment of trans and gender diverse children and adolescents. A move which will surely encourage other countries to take a more proactive approach to helping this vulnerable group of people.
Not all gender variant people actually desire genital reassignment surgery, for the majority, surgery is sought to correct those features that puberty blockers could have avoided, had they been prescribed at an early age: for trans women the Adam’s apple and male facial structure and for trans men the unwanted breasts.
Some trans women undergo removal of the penis and testicles to create a vagina and labia. Trans men can have a total hysterectomy and have a new penis and scrotum surgically created. The results can be amazing, and although surgery should never be undertaken lightly, for some the desire for surgery to complete their transition is overwhelming.
It is worth reiterating that surgery for the potentially gender-misdefining feet, hands, waist, hips and stature, is not safely achievable and it is these features that are preventable with timely medical intervention during adolescence.
Surgery is a very serious consideration and decisions should be made once the child has matured sufficiently, usually well into adulthood.