Important Update: On 28 July 2022 the UK's NHS announced that it was shutting down the Tavistock transgender clinic after a review found that it was “not safe” for children. In the early 2000's the Clinic was a world leader in the treatment of transgender children, treating a few dozen young patients a year. But in 2010's it became increasingly overwhelmed by the sheer number of referrals, which became hundreds and then thousands a year - the majority in their early teens. Children were being recommended to transition and prescribed puberty blockers based on one short assessment. Hormones and surgery would then almost automatically follow as the child reached age 16 and 18. Many parents and patients started to push back on the hastily prescribed treatment, with some children eventually concluding that they were just going through a "phase" and that following the Clinics advice would have been a disaster - perhaps even leading to suicide. This appalling saga shows the vital importance of thoroughly assessing a child who identifies as transgender before any irreversible medical treatment is prescribed.
This article discusses the treatment of transsexual boy-to-girl children. It occurs when an individual is physically born of one sex but is convinced that they are of the opposite gender. Symptoms usually occur early on in childhood, when the individual will play with toys and wear clothes traditionally used by the opposite sex. [Apologies for this gross simplification to the roughly 0.06% of the population who have a genetic intersex condition]
When allowed to, such children are almost always able to rapidly and successfully assimilate themselves into society as a female, this alone is enough to differentiate them from the experience of most transsexual women who transition when an adult.
It is also perhaps necessary to distinguish between intersex infants, who in some cases are assigned a gender contrary to their genetic sex, and children with a Gender Identity Disorder (GID, aka transgender), also often termed Gender Dysphoria. While very young intersex infants have no say in their sex assignment or reassignment (which is usually done before they are 24 months old), transsexual children consciously reject the gender in which they are being brought up at some point between two years old and puberty.
Since the 1960's - when Dr John Money, a physician at Johns Hopkins University, made the medical community at last recognise transsexuality - there has been an ever-increasing incidence of Male-to-Female (MFT) of reported GID cases and requests for treatment across all age groups.
Meaningful statistics on the prevalence of transgender children only began to be collected in the late 1990's. Textbooks published before then commonly state that about 1 in 10,000 children have GID, this number seems be based on a single study made in the 1970's.
In 1997 Press for Change reported that in the UK there were 600 transitioned transgender children. This was less than 1 in 20,000 children.
Note: The figure of 600 excludes the very small proportion of "XY" intersex children born in the UK with ambiguous or malformed genitals who are assigned to the female gender by doctors while still a baby, perhaps 20-40 each year deriving from USA figures. There are also many children with "male" genes who are identified at birth as female and then brought up as girls, for example there are perhaps 3000 "XY" women in the UK who were born with Androgen Insensitivity Syndrome.
However, since 1997 the recorded number of transgender children has exploded. New sources of information such as the internet and TV documentaries mean that children and parents are no longer accepting as gospel the advice of an experienced and over-loaded doctor or psychiatrist. The growth in reported GID cases among teenagers has been extraordinary. For example in 1999 alone, the number of transgendered people under 22 in the "gender reassignment" program at New York's Michael Callen-Audre Lorde Community Health Center tripled!
By the early 2000's the UK's NHS was suggesting that 1 in 4000 children was transgender, the Netherlands and Belgium 1 in a 2000, whilst the number in some Asian countries was reaching 1 in 500 (almost all Male-To-Female).
A UK study published in November 2005 said that there were 2,000 young transsexuals in the country age 15-19, about 1 in 2,500 of that age group.
The newly launched UK Charity Gires had a sceptical reaction when it claimed in 2010 that there were now 26,000 "young people" in the UK with gender identify problems, and that the number would soon reach 100,000, i.e. about 1 in 130 of the UK's population under age 18. However, in 2016 the UK's NHS website was suggesting that 1 child in a 100 had gender problems. A study of 8000 students in New Zealand also arrived at a figure of less than 1 in a 100.
The growth in the number of transgender children in the UK can be illustrated by the exponential growth in referrals to the Tavistock and Portman NHS Foundation Trust in London - which used to be the primary UK centre for children and adolescents with GID:
The UK is far from unique, in 2015 Fenway Health, a highly respected LGBT focused clinic based in Boston (USA) that was founded by local university students published the following graphic showing the extraordinary growth in the number of transgender patients that it was treating:
By 2021 the number of transgender patients being treated by Fenway was over 4,400. Although its transgender patients are generally "particularly young", since at least 2020 the clinic has been seeking to better support "older adults".
The UK's NHS reported that the average (mean) age of patients being referred to its gender identity clinics in 2013 was 42. In 2015 it was just 30 after repeated huge annual rises in the number of teenagers with gender disorders - the Sun newspaper suggested 1000%.
The balance has also changed from female-to-male (FTM) children greatly outnumbering female-to-male (FTM), to the exact opposite - the Tavistock clinic now has more than two FTM referrals for every MTF. The referral of young people assigned female at birth (AFAB) to NHS gender clinics now outnumber male at birth by more than two to one, although among adults the opposite is still true. One study estimates that "just" 2-6% of natal boys exhibit cross-gender characteristics, compared to 5-12% of girls.
With the increasing awareness and more favourable publicity given to transgender, MTF children who in the past would have suppressed their female gender, or at least defer dealing with it openly until reaching adulthood, are now coming forward while still a child. In most cases their families respond very positively and supportively, but occasions of outraged parents and internal family battles about how to deal with a would-be daughter will never cease completely. Perhaps a good indicator of the changed situation is that by 2016 about 90% of UK primary and secondary schools had policies to support transgender students.
There continues to be a reluctance by the general medical profession to pro-actively treat gender identity disordered children. In the UK a referral to the few specialist NHS clinics is the best outcome, although these are being overwhelmed by numbers that are roughly doubling every year. It is also worth noting that young transsexuals (i.e. under age 20) seeking and obtaining medical help and treatment at these clinics are still vastly outnumbered by their older counterparts - most of whom bitterly regret their years of delay. But a major problem is that the NHS's waiting list for GID treatment is two years, and additional resources are desperately needed. There is strong case that younger transgender patients should be prioritised over older patients - unfair though this may seem to the later.
Young transgirls tend to immediately and successfully go stealth after transition, unlike their older counterparts. The girls pictured on this page are thus exceptionally brave about their transsexuality - or had little choice as they were out'ed by the media.
A person's sex can be determined or judged by many factors, including:
It is quite possible for these factors to disagree and contradict, e.g. a post-operative transsexual person may have a male birth certificate, a male karyoptype (XY genes), no internal female sex organs, female appearing genitalia and secondary sexual characteristics, live and identify as a woman, but be sexually attracted only to other women and in a lesbian relationship.
Factors 6, 7 and 8 are commonly and unfortunately combined under the term "gender-role", but I prefer to keep them separate when possible. A particularly confusing but frequent use of the word gender is in the phrase "Gender Re-Assignment Surgery" (GRS). It's essential to differentiate between a person's physiological sex (factors 4 and 5), and a person's social & mental gender (factors 6 and 7), surgery can't ever change the later and phrase "Sex Re-Assignment Surgery" (SRS) is a better, although still seriously exaggerating, description of what surgery can achieve.
For most children their legal, chromosomal and physical sex agree with their mental gender and preferred gender role.... but not always. As already mentioned, children with gender identity problems are described as having gender dysphoria.
Establishing a gender identity is a process that most people take for granted, but that no one completely understands.
Scientists and sociologists agree that traditional gender roles are in many ways socially constructed, e.g. girls learn to wear dresses and boys learn to wear trousers. But no one seems to understand what makes a transsexual child raised in a male gender role embrace the female role as her own and vice versa. Nor can anyone explain why many intersex children raised as one sex eventually migrate back to the gender that their genetics or their prenatal hormonal environment would have predicted.
Bill Summers, a professor of medical history at Yale who has studied the science behind gender and sexuality says "You have to learn somehow what it means to be a boy or a girl. You don't come born with this idea. But enough people say, 'I always knew I was a boy but I was raised as a girl' that I can't doubt they have these feelings."
Summers points to the work of Dr John Money who became famous in the 1960s for recommending and surgically facilitating the transition of a young boy with a botched circumcision into living as a girl - the so called "John/Joan" case. Money initially declared the gender re-assignment to be a success, but his work was later undermined when the girl grew up with a masculine gender identity anyway. Summers notes that "the whole idea [was] that given hormone treatment and the right social environment, you can determine gender identity. It's not really quite so simple."
The bottom line seems to be that sociologists and psychologists still don't know where gender identity comes from or why - but it is unlikely that either biology or society operates totally independently from the other. The only current certainty seems to be that when a young child decides that they are a boy or a girl and this decision contradicts their supposed physiological sex, the result is much anguish and cost to the child, the parents and the medical profession.
Identification of Transsexual Children
Whilst there is no such thing as the typical young child with GID, perhaps a good example is Zach Avery. At first, he seemed to be a 'normal boy' but when age 3 he turned around and told his mother, Theresa, "Mummy, I'm a girl". She assumed that he was just going through a phase and just left it at that, but Zach started to insist on wearing his sister's clothes and would become upset if anyone referred to him as a boy. Theresa notes that "He used to cry and try to cut off his willy out of frustration". His parents became increasingly worried by Zach's behaviour and took him to the doctors. After numerous consultations and observations, he was officially diagnosed by NHS specialists as having GID, and transitioned age 4.
A key, if obvious, differentiator between transsexuality emerging in children and the far more numerous instances of it emerging in an adult is the pre-puberty age at which noticeable cross-gender behaviour appears in the former group. This has been confirmed by numerous studies...
In one study, two thirds of transsexual boys were aware that they belonged to the opposite sex and exhibited such behaviour by age 5, and 77% by age 10.
Another study of 137 MTF transsexuals, 70% exhibited cross-gender behaviour before age 10, and another 20% before age 15.
A third study of 121 transgender individuals between age 18 and 65+ gives a modal average of 5 years for the age when the participants began to question their assigned gender, and a mean average of 7.9 years. Just 4% first had doubts about their gender after age 18. Over 80% of the participants in the study were assigned male at birth.
It seems that until the 2010's most young transsexuals suppressed their doubts about their assigned gender, as one later said "my overriding need was to a keep it quiet and not come out and seek acceptance that 'God has made a mistake'".
But there were brave exceptions. For example Richard ('Richie') always wanted to wear dresses like his sister, when age two and a half his mother caught him trying to cut his penis off with nail clippers, saying "this doesn't go here". At age 7 he was finally diagnosed as having Gender Identity Disorder, his parents changed her name to Riley Elizabeth and let her go to school as a girl - where she blossomed from a "sad confused little boy into a happy young girl". The financial burden of Riley's medical care had been crippling, but her parents had no doubts - "seeing Riley's happy face now, it's worth every penny".
It seems that at least three-quarters of gender dysphoric children will eventually have sex re-assignment surgery (SRS).
If clinical testing finds that the following conditions apply:
then core transsexuality, commonly known as "true" or "primary" transsexuality, is likely to be confirmed and appropriate sex-reassignment treatment should be started.
However there still remains considerable reluctance by the medical profession to supportively treat a physically normal boy with gender identity problems - a boy who's adamantly insistent that he's really a girl. The sex re-assignment of babies and very young boys became medically acceptable in the 1970's and 1980's (indeed, perhaps too common) - but has since become discredited and unfortunately there has been a carry-over affecting young transsexuals. It seems too often require courageous and forceful parents before doctors will medically facilitate the transition of a minor.
Another interesting (aka confusing) development since 2010 is that several studies suggest that more than two thirds of boys diagnosed with gender dysphoria when pre-puberty, accept that they are actually male when post-puberty. This however opens a host of questions about the amount of medical support that they received, their access (or lack of) to puberty blockers and hormones, an inability to transition, social and family pressures, sexual orientation, and the long term physical and mental consequences - particularly on those girls still diagnosed with gender dysphoria.
An understandable reluctance to "come out" to one's parents remains probably the greatest single obstacle to the early and successful treatment of many transgirls. On the other hand, things do seem to be improving and television and the Internet is playing a key role in this - these days most transsexual children first learn about "transsexuality" from TV programmes, relating to this condition they - and often their parents - seek further information via the Internet (now an extraordinarily valuable resource) and from books.
It is impossible to underestimate how important the understanding and support of parents is for a young transsexual her eventual success in life. It is also difficult to underestimate how much emotional strain having a transsexual child can impose on his/her parents.
Many parents become a pillar of support and understanding, indeed there are many instances of parents going to extraordinary lengths and expense to aid their new daughter - for example moving house so they can go to a different school and avoid anyone who knew them as a boy.
In another positive example, Jamie never felt herself to be a boy, and when at age 11 she finally told her parents "You think that I am a boy, but I am a little girl!", they accepted her choice and she is now living very happily and confidently as their daughter.
On the other hand, there are also instances where the child tells the parents and the result is a nightmare of arguments and pressure. Rachel (formerly Daniel) describes how when she told her parents at age 17: "They didn't shout at me but the conversation was very heated. Mum got upset - although she said she'd guessed a while ago - and Dad was annoyed. They both said they didn't want me to dress up in the house and that I'd always be Daniel to them. ... My parents have been good to me, but they'll always see me as their son."
Rachel is actually luckier than many girls. Enforced visits to a suitable psychiatrist (suitable for the parents at least) to treat the child's gender disorder are common. Perhaps in a few cases a "cure" is achieved, but more commonly the child suppresses his/her transsexuality, and if he persists then an eventual total rejection by one (usually the father) or even both parents may well occur. For example, Brazilian Roberta Close was disowned by her father, and only reconciled years later. While now a successful model and actress, for several years in her teens Roberta descended in to the seedier side of life that all too many transsexual women go through in order to earn a living.
Often transsexual children feel unable to tell their parents
about their feelings and needs. This usually means that a public
admission of their transsexuality is deferred to adulthood - and the delay
is always much regretted. But also the resourcefulness of children
should not be underestimated. For example, one textbook (Man and
Woman, Boy and Girl) describes how a woman secretly obtained and took
hormones while still a young teenage boy. Her concerned parents
eventually took her to hospital for tests to help determine the cause of the
resulting physical changes, but she had had enough warning to stop and let
her system clear. The doctors concluded that the changes were
spontaneous and natural (some degree of gynaecomastia - male breast
development - is quite normal in mid-puberty boys), and told the parents not
Medical Guidelines for the Treatment of Transsexual Children
The widely followed HBIGDA Standards of Care of Gender Identity Disorders, a document which has previously (and increasingly controversially) been against the treatment against the hormonal treatment of under 16's, has relaxed its rules somewhat in the latest (2001) Version 6. It now states that:
Although still not coming out in favour of starting feminizing hormone treatment at a normal puberty age and delaying any sex change surgery until at least age 18, the standards do at least now allow the treatment of very young adolescents with puberty-delaying hormones and thus help prevent the socially and mentally disastrous development of normal male [secondary] sexual characteristics and appearance in an under-16 MTF school girl. In a best case this now allows age critical medical treatment to stop male characteristics developing, but female sexual characteristics optimised by early hormone treatment are still banned.
In its defence, the "Standards of Care" is clearly and understandably concerned about some instances of unsuccessful boy-to-girl gender re-assignment of intersex babies, such as the highly publicised failure of the gender re-assignment David Reimer (aka the "John/Joan" case), and wants to avoid any future repetition.
Puberty is often a nightmare for 'gender dysphoria' children according to Cohen Kettenis, Professor of Psychology at the Medical Centre of the Free University in Amsterdam, "They develop an enormous dislike for their body." Most children seen by Professor Cohen react with horror to the changes that occur in their bodies at puberty. It appears that their so-called "transsexual" feelings become much stronger and they do not feel at home in the body that they now developing. Margaret Griffiths of the Mermaids support group says very similar things, "Some girls and boys go through Hell at puberty, they have few friends, they are bad in the school, because they can concentrate on nothing, and some have suicidal thoughts."
When - at age 10 - Riley (who had been living as a girl since age 7) was warned by her mother that nature would soon start turning her in a man, her reaction was a horrified "Please don't let that happen ... please!".
Although the child may not admit to his transsexual desires at this stage, the parents will often start to have some concerns about their son. The onset of puberty is a critical point as the child is faced with his own undesired physical masculinisation, often combined with a great jealously of girls and their physical changes, by age 15 some 90% are exhibiting feminine behaviour. This is the point where many transsexual children finally admit to their wish to be a girl and they, or their parents, seek help.
One now happily post-SRS girl described how she felt at puberty: "That was the hardest. My own body was staging a mutiny, even." At 16 she finally confessed to her secret to her parents who took her to several doctors but they wouldn't help, "I knew I couldn't be happy letting my body masculinize on and on. And so at 17 I graduated from high school and found hormones on the street."
Zoe, age 21, concurs about puberty: "When puberty arrived I was repulsed by my erections and deepening voice. At times I felt suicidal."
Jamie Cooper was 12 when she wrote her mother a letter saying that she should have been born a girl, they sought medical advice and were told that it could just be puberty, the feelings deepened but she had to wait until she was 16 before receiving hormone treatment - she transitioned on her 16th birthday.
A lot more information about puberty and its effects is given in the
Professor Cohen's policy is that if it appears that the gender dysphoria feelings are becoming stronger, then they should be prescribed puberty blockers to temporarily halt puberty until they are 16. When they are 16 and quite certain that they have the wrong body, they can be prescribed hormones as well as to begin to change their outward appearance to more closely match their chosen sex, "After that comes the actual sex-change operation".
A photo from 2021 showing four Australian transgirls, from the left Grace Hyland (age 21),
Evangeline Macdonald (age 17), Belle Bambi (age 23) and Avery Clemens (age 25). They began taking
female hormones or puberty blockers at ages 18, 10 (blockers), 13 (blockers) and 18 respectively. (Australia)
of Early Treatment
Nevertheless, many gender clinics seem to be moving the earliest age for the prescription of hormones rather than puberty blockers to transgender children from age 18 to age 16. All the accumulating evidence is that the earliest possible hormonal treatment has significant physical and mental advantages - even compared to puberty blockers.
There are two key problems with puberty blockers for a boy to girl:
1. Boys tend to start puberty later than girls. It is very unusual for a boy to be prescribed puberty blockers until age 11 or 12, by which time most girls are several years in to their puberty.
2. Puberty blockers stop the development of male secondary characteristics but they don't stop the clock. The human body seems to be fundamentally geared for dramatic sexual development between ages 10 and 15. Stopping blockers and beginning female hormones when age 16 is simply too late, the frequently disappointing breast development of many such girls who start taking oestrogen in their late teens is strong evidence of this.
If a boy is diagnosed as a transsexual then a failure to immediately start treatment is not only deferring the inevitable in the vast majority of cases but is doing so at a considerable cost to the child's future as a girl and woman. It's indisputable that the earliest possible transition and pre-puberty hormonal and surgical treatment will offer most boy-to-girl's massive psychological and physical benefits.
An example of this is Ariel Nicholson Murtagh. He knew from a very young age that he was actually a girl. Her mother, Kerry, was very supportive and battled for his right to transition and receive medical support. [Sadly her father was far less supportive, and this was a major factor in the marriage ending.] When age 10, his mother let her transition and change her name to Ariel, she also began injections of Lupren to suppress her puberty and prevent her voice from breaking. In 2015, age 14, she appeared in the PBS documentary “Growing Up Trans”, talking with a therapist from the Ackerman Institute about wanting to take oestrogen. She finally started taking hormones age 15. The PBS documentary resulted in her being discovered as a model, her first catwalk was for Calvin Klein in September 2017, in 2018 the influential models.com website added her to their "Hot List".
Another example of the results of early medical treatment is Wyatt and Jonas Maines. They were born identical twins, but from a early age Wyatt rejected being a boy. His parents were very supportive, and at age 11 the twins became brother and sister when Wyatt transitioned and changed her name to Nicole. The family sought medical help from the Children’s Hospital Gender Management Services Clinic in Boston, USA. The clinic prescribed Nicole with puberty blockers and female hormone injections. The dramatic effect of this treatment is shown by the fact that at age 14 Jonas (in mid-male puberty) was 167 cm tall (5ft 6 inches) and weighed a 52 kg (115 pounds), whilst Nicole was still a petite 155cm (5ft 1inch) and weighed only 45kg (100 pounds).
Supermodel Teddy Quinlivan, risked her career when in 2017, age 24, she decided to tell a CNN reporter that she was transgender. She emphasised that her success as a female model was due to transitioning and beginning hormones at a young age:
Early transition and commencement of treatment will permit the transsexual boy-to-girl a female childhood, a normal puberty (excludinoman. It's an absolutely priceless experience if a transsexual girl goes through her adolescence and growing-up as a female, with a circle of same-sex girlfriends. It's a period of time when her personality, identity and attitudes are forming, and the stage for the rest of her life is being set. She will have irreplaceable girlish memories and social adjustments that a transition later in life can never give her. Her life experience will be much more like that of other women, she will be able to talk more easily about parts of her past, her school days, and even have photos to show her future boyfriends. For many girls, denying these experiences to her and enforcing an unwanted male gender is simply a disaster.
One successful transsexual woman 'Anna Taylor' describes her early experiences: "It never occurred to me that I was a boy. I just wondered why I had something extra. I had sessions with a child psychologist and my parents were told to bring me up neutrally. My mother tried, but my dad would slap me if he caught me playing with dolls. My mother says that if it had been up to her she would have banged on every door to let me become a girl, but my dad wouldn't stand for it."
Monica was born a boy named Morten, but always rejected being assigned as male. By her teens, her parents were worried that she was becoming suicidal and supported her transition. She finally had full SRS at age 22.
Anna ran away from home several times until, aged 8, she went to live with her grandparents who were prepared to bring her up as a girl. At age 11, started at a new school where the headmaster was very sympathetic and agreed to let her register as a girl. "For the first time no one was laughing at me. From being very withdrawn, I became very bubbly and outgoing. The only allowance they made was that I had to change in a separate cubicle for games and use the teachers' toilets. The school was afraid of another girl seeing something they shouldn't. [But] I got very depressed when the other girls started wearing bras. My own doctor wouldn't prescribe hormones for me at 13, so my grandmother took me to Amsterdam to find a doctor who would. Within a few months I'd grown very small breasts. Doctors agreed that I should have had gender reassignment surgery when I was younger but now that I was an adolescent, I would have to wait until I was 18."
A recent follow-up study of sex-reassignment in 22 adolescent transsexuals (ten started hormones under age 16, twelve under 18) found that post-operatively in all cases all signs of gender dysphoria had disappeared, they scored normally in psychological tests and they were socially functioning well. Not a single girl/boy expressed feelings of regret concerning their decision to undergo sex reassignment. The study concluded that with careful preliminary screening, starting sex reassignment procedures before adulthood results in favourable post-operative functioning.
Transgender Girls and Hormone Treatment
A doctor now treating transwomen says: "I began working with transgendered people in their 20s. The people in their 20s were socially in good shape. But they were having trouble getting their physique to conform to their identity. I knew the twenty-somethings could have better chances of passing if they were treated earlier."
Early hormone use (i.e. during puberty) in a trans-girl allows a typically normal female body shape to develop, with significantly more fat and less muscle than otherwise, the girls post-puberty body shape and "figure" will become far closer to female than male norms in its proportions.
In general, increased levels in the blood plasma of oestrogen and progesterone will stimulate and promote the growth of female secondary sexual characteristics (breasts, fat distribution, pubic hair pattern, ...) while the reduction in the levels of androgens such as testosterone will, if early enough, completely prevent the development of male ones (deepening of voice, facial hair, muscular development, ...).
Female hormonal treatment has a dramatically greater effect if begun before a male puberty has started (on average age 12, but plus or minus 2 years) than after a male puberty has completed (on average 17, plus or minus). This is a severe problem given the great reluctance to doctors to assist transsexual patients under age 18. Incidentally, the anticipated and achievable benefits from starting female hormones decline rapidly in the decade after puberty ends.
Maximum possible feminisation occurs if hormonal treatment begins before a male puberty would have start started. Very conveniently, girls tend to start puberty two years earlier than their male peers, so high dose hormone therapy intended to initiate a full female type can be safely started by age 11, although it in practice it is often deferred to 12 or even later, particularly if the individuals physical development allows that. If her testes were removed in infancy or childhood, then for health reasons low level hormone therapy should be begun by age 9 - an age at which many girls begin to notice some initial puberty changes, in particular the development of breast buds.
As indicated already, surgeons have become very reluctant in recent years to perform a bilateral orchiectomy on even young intersex patients, let alone gender dysphoric boys; however failure to do so does accept the slight risk that even suppressed testes might still produce enough androgens for a very sensitive body to react to them. The nightmare scenario is a confused body going through a double male and female puberty - the girls hips broaden, and her breasts swell under the influence of oestrogen therapy, but simultaneously her voice deepens and facial hair appears due to the testosterone being produced by her testes.
Surprisingly there seems to have been no serious medical studies examining how pubertal development differs between genetically 'XX' cis-girls with estrogen producing ovaries and young 'XY' girls (commonly intersex rather than transsexual) on hormone replacement therapy (HRT) following early orchiectomy.
In a genetic girl, her increasing production of oestrogen during puberty causes her skeleton to mature so that growth eventually stops. Oestrogen treatment can speed up this bone maturation by accelerating the completion of growth in the growth plates (the zones of growing cartilage near the ends of children’s bones) and thus suppresses growth somewhat, by up to two inches. Paediatric endocrinologists sometimes prescribe large doses of oestrogen (usually Ethinyl Estradiol) for a period of several years to deliberately restrict growth in excessively tall girls, and the same technique can be used to help induce in young transsexuals a final height in the typical female range of 61 - 67".
However, obtaining supervised treatment for a transsexual boy-to-girl is difficult, arguing that height is not a disease; endocrinologists are becoming increasingly reluctant to treat even a genetically female "XX" adolescent unless bone growth X-rays show that excessive adult height for a female (over 71") appears likely.The Brain
During puberty the human brain undergoes its final stage of growth and development. Despite decades of speculation there is very little evidence for significant differentiation based on genetics (XY vs XX). It's even less clear if there are gender related differences - perhaps stimulated by hormones. The study of transgirl's and transboy's may lead to some important results.
The Benefits of Early Hormone Treatment
A treatment model developed for intersex children with male testes but assigned as female has occasionally been applied to young transgender children. In order to maximise physical feminisation, low level oestrogen treatment of the young transsexual boy-to-girl often begins at age 8-9 years. Before the onset of a natural puberty (at about age 11, but it can vary ±2 years) a bilateral orchiectomy (castration) is performed to remove the testes and hormonal treatment is then increased (additional oestrogen, later supplemented with progesterone) to initiate a female type puberty.
When an orchiectomy is performed before puberty, the results in terms of increased physical feminisation and decreased masculinisation are much more dramatic than when it is done after puberty. However, many Western doctors are very reluctant to perform any irreversible surgery, or even prescribe feminising hormones, for a transgender child under age 16. Instead, they often prescribe GnRH analogues (commonly known as 'puberty blockers') such as Zoladex (Goserelin Acetate) and Lupron (Leuprolide Acetate). These prevent or dramatically reduce gonadal hormone production, including testosterone, thus preventing the onset of the masculinising changes of adolescence. The drug is administered with a nasal spray, or via a weekly or monthly subcutaneous injection into the abdomen. While the treatment does nothing to promote female physical characteristics in the girl, it does prevent or greatly slow male type puberty with its physical effects, and several Dutch studies have confirmed the effectiveness of such treatment.
Puberty blockers have the important advantage of gaining time whilst the transgender child considers and reconfirms their choice of gender. The 2010's have seen a huge increase in the number of apparently transgender children, but anecdotal reports indicate that up to a third change their mind within a year of transitioning. Another big advantage of blockers for a boy-to-girl is that they don't have to start taking a high dose of oestrogen whilst pre-teen. An 11 or 12 year old boy is actually shorter than the average girl of the same age, and starting oestrogen therapy at that age may restrict their height to under 5ft (about 151 cm) - very short even for a girl. Obviously every transgirl is different but delaying oestrogen treatment until age 13 or 14 is likely to result in an average female height, whilst 15 may result in an above average height for woman, but not excessively so (i.e. ideal for a model).
Unfortunately GnRH analogues are expensive drugs, but they are to be much preferred in adolescents over the cheaper anti-androgens such as Aldactone (Spironolactone) and Proscar (Finasteride) which are commonly prescribed to post-puberty transsexual women, but which are increasingly suspected of having unwanted side effects, including reduced breast growth.
The UK's NHS has become one of the most progressive medical organisations in regards to the treatment of transgender children. They will now - if appropriate - prescribe hormones from age 12, and puberty blockers before that.
Even if it not possible to begin female hormonal treatment before a male puberty has commenced, the results can still be remarkable results if started whilst the body is still at its most receptive age - the critical puberty years between about 11 and 17 (depending on the individual), but the earlier the better. It is no coincidence that so many transsexual women who famed for their looks had begun taking hormones by 17 - Jenny Hiloudaki, Tula, Hari-su, Roberta Close, Dana International, etc.
A typical example is Nicole Vicky Eriksson, born in 1995 in the small village of Stråtjära, in Hälsingland, Sweden. She was christened Victor, but always knew that she was a girl trapped in the body of a boy - when asked age 3 what he wanted to be when grown up, she responded "A woman!". Her family and the people of her home village accepted her transgenderism, and she began taking hormones at the age of 16 years, with her sex change operation planned for 2013, when she reached 18. She moved to Stockholm to study fashion and dreams of a career as a model, and her ImVicky blog already has a huge following.
Doctors certainly seem to agree that giving - for example - a 13-year-old transsexual boy-to-girl doses of oestrogen will make her physically far more attractive as an adult woman. However they also agonise about the possible negative consequences - and perhaps their potential legal liabilities from prescribing female hormone to "boys".
Young transsexuals often struggle to understand the medical "best practice" guidelines that affect their life. Riley (pictured right, age 9) was when 12 diagnosed both oestrogen and testosterone blockers. It was explained to her that this would make her body more feminine, her voice won't deepen and that she could eventually develop breasts - but that she would be infertile. Her reaction was "But I can adopt babies ... why can't the doctors take my testicles off now?"
A rare example of the medical community responding to the needs of young transsexual may have achieved in Germany when it was revealed in 2007 that doctors had prescribed puberty blocking and later female hormones to a 12 year old 'Kim', formerly Tim. At age two, Tim was trying on his older sister's clothes, playing with Barbie dolls and saying "I'm a girl." By age four Tim was refusing to get to his hair cut and wanted to cut of his "thing", for the sake of a normal life his parents increasingly accepted their son Tim as being their daughter Kim.
The situation reached a crisis when Kim grew increasingly distressed at becoming like other adult transsexuals with big hands and deep voices, whom she thought looked ridiculous when they dress like women. Her father said "We saw Kim as a girl ... not as a problem. ... [she] reacted badly to the first signs of puberty... At that stage we realised that she was terrified of growing facial hair and her voice breaking".
Kim’s parents decided to help her get a sex change and consulted psychiatrists across Germany. Some condemned their support of their child’s desire to undergo a sex change, or suggested that she be kept under observation in a closed psychiatric ward. But Dr Bern Meyenburg, the head of a clinic for children and adolescents with identity disturbances at Frankfurt University, concluded that the child was serious. He wrote in his diagnosis: "Kim is a mentally well-developed child who appears happy and balanced. ‘There is no doubt of the determined wish, which was already detectable since early childhood. It would have been very wrong to let Kim grow up to be a man."
Dr Meyenburg had once strongly opposed hormone treatment for children but changed his mind when one of his patients refused to listen and ordered hormones over the internet, then went abroad at 17 and had a sex change operation for a few thousand euros. Dr Meyenburg admits that he was angry at the time, but said that today the woman is a law student and one of his happiest patients. He now allows young patients to enter hormone treatment early, before puberty complicates a sex change. "They simply suffer less," he said, "it would have been a crime to let Kim grow up as a man".
Dr Achim Wuesthof, who is now treating Kim at a clinic in Hamburg, said: "Imagine a man who suddenly starts growing breasts or a woman who starts growing a beard against their will – that is how Kim and people like her experience puberty." Kim was thus prescribed female hormone therapy when just 12, and by age 14 was fully transitioned and living as a girl - with her identity and medical insurance cards changed to her new name and female sex. German law only permits sex-assignment surgery (SRS) at age 18, but Kim apparently had this in November 2008 - just two months after her 16th birthday. This created headlines around the world that proclaimed her to be the youngest person to ever have had SRS, although that claim is false - even excluding XY intersex children. Just two examples are the sad case of David Reimer (age 22 months), and Victoria Beltran whose parents managed to get her surgery when just 15. Also, hundreds of SRS procedures are performed every year on under-18's in Asia and South America, and it seems very likely that some are under 16.
Kim handled the intense media interests surrounding her surgery with great honesty and confidence, for example she told one interviewer "I was asked if I feel like a woman now - but the truth is I have always felt like a woman - I just ended up in the wrong body." Since age 18, Kim has concentrated on developing her a career as a singer.
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