TRANSSEXUAL children as young as 12 should be given drugs to postpone puberty and make it easier for them to change sex at the age of 16 if they still want to. That鈥檚 the suggestion of controversial , the first of their kind, issued last week by the international Endocrine Society.
The guidelines state that transsexual children and young teens who have begun early puberty should be given puberty-blockers to avoid inevitable changes to their bodies, which they perceive as out of line with their true gender. In the worst cases, these changes can drive children to self-harm or even suicide.
The idea is to buy thinking time for young people so they can decide if they want to begin a sex change using hormones when they are older. Puberty-blockers would also make life easier when transsexuals become adults. Male-to-female transsexuals, for example, will not have the deep voice, masculine bone structure and body hair associated with adult men. However, surgery should be avoided until the age of 18, the guidelines state.
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Nonetheless, the guidelines are likely to provoke heated debate. What if transsexual teenagers change their minds when they get older? According to previous studies, transsexualism persists into adulthood in only 20 per cent of boys who show signs of distress in childhood, for example. And although the effects of puberty-blockers are not permanent 鈥� natural puberty should resume if the drugs are stopped 鈥� few trials have explored the long-term effects of delaying puberty in this age group.
To reduce the chance of giving drugs to a child who later changes their mind, the guidelines state that treatment should not start before the first stages of puberty have begun 鈥� when female breasts have begun to bud, and boys have experienced a slight enlargement of the penis and scrotum. This is because the emotional reaction to these changes can help predict whether someone will persist in their wish for a sex change.
The recommendations are largely based on the experience of a clinic in the Netherlands which has so far prescribed puberty-blockers to more than 70 under-16s. The youngest was 11, and the majority are 12 or over. 鈥淯ntil now we don鈥檛 have any patient who has regretted their decision on the treatment,鈥� says Henriette Delemarre-van de Waal of Leiden University Medical Center, who helped to treat them.
A thorough mental and emotional assessment of the child is essential, so that puberty-blockers are only given in extreme cases, she says, a sentiment echoed by the guidelines.
Many countries, including the UK, refuse to allow medical intervention for under 16s 鈥� by which time puberty is usually in full swing. However, clinics in Canada, Australia, Germany and elsewhere, plus a handful in the US have begun to offer the treatment.
Those supporting their actions say puberty-blockers can be hugely beneficial. Take Sarah in London whose daughter George started to question her male body from age 4, and found the changes that started taking place aged 12 intolerable. She began to self-harm, and even threatened to cut her penis off several times. 鈥淚t was awful,鈥� says Sarah. 鈥淪he was devastated and disgusted that things were happening to her body that she couldn鈥檛 understand.鈥�
The Dutch team assessed her, and said that if she lived in the Netherlands they would prescribe puberty-blockers 鈥� in fact, George eventually travelled to the US to get the drugs when she was 13.
George鈥檚 feelings are typical of those experienced by transsexuals when puberty begins. 鈥淭hey self-harm, they develop an enormous aversion against their bodies, they isolate themselves and their school performance suffers,鈥� says Delemarre-van de Waal.
The permanent changes that occur during puberty can also cause lifelong torment (see 鈥淐ase study鈥�). 鈥淚t is distressing as an adult that these changes at puberty stand in the way of your appearing as a man or woman,鈥� says Richard Green of Imperial College London, who runs a clinic for adult transsexuals.
But doctors opposed to early treatment say that young people may not fully understand the full consequences of their actions. For example, blocking puberty in boys who later go on to have hormone treatment and surgery that turns them into a woman means that they will never produce mature sperm. In contrast, boys who don鈥檛 change their gender until after 16 could bank mature sperm before undergoing a sex change, allowing them to 鈥渇ather鈥� children should they decide they want to do this.
Russell Viner of the Institute of Child Health in London cites the case of a transsexual man who had both surgery and hormones to become a man, but still wanted to become pregnant. 鈥淭hat may not have been possible if they鈥檇 had early intervention,鈥� he says. 鈥淲hen is it reasonable to let a young person remove major life choices?鈥�
Marvin Belzer of the Children鈥檚 Hospital Los Angeles, who has treated several 12 and 13-year-olds with puberty-blockers, agrees that there are some difficulties, but says the benefits need to be weighed against the risks. 鈥淪ome day there鈥檚 going to be a kid we鈥檝e treated who comes back and says 鈥業t was wrong 鈥� I wish I hadn鈥檛 done it鈥�,鈥� he says. But he emphasises that this isn鈥檛 necessarily a reason not to give puberty-blockers early on. 鈥淭he question is can we go back and say, 鈥榊es, but you and your family gave informed consent, and we knew that was one of the risks, but that risk was small鈥�?鈥�
Peggy Cohen-Kettenis of the Free University of Amsterdam Medical Center, who helped write the new guidelines, agrees: 鈥淧eople are always afraid that it 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.鈥�
鈥淧eople worry that the drugs will harm children, but what they never take into account is that it is harmful not to treat them鈥�
Transgender support groups welcome the guidelines. 鈥淚t is an excellent piece of work,鈥� says Bernard Reed, a trustee of the in Ashtead, UK. He hopes the guidelines will encourage UK doctors to consider the option of early treatment.
In the US, Belzer also hopes the guidelines 鈥� which offer advice on treating adult transsexuals as well 鈥� may encourage insurance companies to cover more of the medical costs of treating gender identity disorder. Puberty-blockers cost around $800 a month.
George, now 15, is still taking puberty-blockers and would like to begin sex reassignment when she turns 16. Sarah knows George will still have difficulties, but she says they would be 鈥渋ncreased by 600 per cent鈥� if she鈥檇 gone through male puberty: 鈥淪he stated categorically that 鈥業 would rather die than be a man.'鈥�
Case study: PUberty is hard to undo
The first memory Celia MacCleod has of being transsexual is a school matron telling her at age 8 that she was too pretty to be a boy. 鈥淚 remember the surprise I felt that she knew,鈥� she says.
It took a further 52 years for MacCleod (left) to act upon her convictions. Shortly after her 60th birthday, she announced that she was planning to undergo the surgery that would make her look more like the woman she knew herself to be.
MacCleod鈥檚 forehead, nose, jaw, and chin were re-contoured, and her upper lip was shortened, so that when she smiles you see her top teeth rather than her bottom teeth 鈥� a typical female characteristic. Her Adam鈥檚 apple was also reduced, and she had laser treatment to remove body hair on her arms, legs, underarms and abdomen.
Now aged 63, she is still having electrolysis once a week to remove facial hair. 鈥淚t鈥檚 painful and it鈥檚 tedious but we鈥檙e nearly there,鈥� she says.
But some characteristics are more difficult to reverse. 鈥淵ou can never really undo the vocal changes that happen during puberty,鈥� says MacCleod. While she has had an additional operation to help raise the pitch of her voice, she still has 鈥渟ome awful telephone encounters鈥�.
Many of these problems would have been avoided, had MacCleod been given puberty-blockers during early adolescence to prevent her developing the characteristics of an adult male.
As a result, she welcomes international guidelines that recommend giving such drugs to young teenagers with strong transsexual feelings (see main story). 鈥淚 think it will make it easier for people to express themselves and ask for help,鈥� she says. 鈥淭he idea of being able to have that breathing space of putting puberty on hold and knowing that you鈥檙e not getting these irreversible changes, I think that鈥檚 breathtaking.鈥�
If MacCleod had felt comfortable expressing her conviction about her true gender at a younger age, she says it would have been valuable: 鈥淚 would have emerged as quite a pretty young lady with a lot of confidence.鈥�