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.

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 (of all ages)  to the Tavistock and Portman NHS Foundation Trust in London - which used to be the primary UK centre for children and adolescents with GID:

Below is another table from the Trust which provides a more detailed breakdown for referals age 17 and over.  Three standouts from this are:

• A slowing of year-on-year referral growth from the previous  50% p.a. to perhaps 20%

• About half of all referrals are age 20 or less

• FTM referrals dominate age 20 or less, outnumbering MTF referrals by about 2.5:1.

The UK is far from unique in seeing an upward trend.  The chart below compares the UK's experience with Australia, their respective populations in 2019 were 67 million and 26 million so the relative difference on the linear trend rates is small.

Similarly, 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.

The results of an EU study asking individuals suffering from GID when when they first realised that their gender did not match that assigned at birth.

Undoubtedly the overall growth in numbers is largely the result of increased access to information.  A child today with 'gender dysphoria' - the catch-all term for disconnect between body and gender identity, will almost certainly have heard about transsexuals and transgender long before they reach the critical point of puberty.  Many children with GID problems learn about transgender from TV shows and documentaries and then go on-line, looking up anything and everything they can find out about transsexuality, and start to chat and email with other transsexuals.  For example, the 2014 American reality TV series I am Jazz starred a 14-year old transgender girl, Jazz Jennings, whilst UK television had the series My Transgender Kid. 

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.

Born in 1992, teenager Kim Petras (born Tim) became world famous when it was inaccurately reported that she was the youngest person ever to have had SRS - at age 16.(Germany) An attractive if obviously staged photo of Vicky (born Victor) Eriksson after her transition, age 16. (Sweden)

Sex Re-Assignment

A person's sex can be determined or judged by many factors, including:

1. Legal Sex:  In the UK the infamous ruling by Lord Justice Ormrod, irreversibly determined that this was the sex stated on the original birth certificate - although since 2004 the Gender Recognition Bill has overturned many aspects of this ruling.
2. Hormonal Sex:  Based largely upon male type testosterone plasma levels, or female type oestrogen and progesterone plasma levels.
3. Chromosomal Sex:  Male "XY" or female "XX" genes as determined by a karyotypic study (in rare cases there are other combinations.
4. Internal Sexual and Accessory Organs:  The presence of male (testes) or female (ovaries) gonads, and male (e.g. vasa deferens, ejaculatory ducts and prostate gland) or female (e.g. uterus, vagina, fallopian tubes) accessory organs.
5. External Sexual Characteristics:  Male (e.g. penis, scrotum) or female (e.g. clitoris, labia majora) appearing external genitalia, and other male (e.g. beard) or female (e.g. breasts) appearing secondary sexual characteristics.
6. Gender Role:  The sexual role a person lives in, and the sex they are perceived as being.  A reasonable definition is "A social status usually based on the convincing performance of femininity or masculinity".
7. Sexual Identity:  The physical sex a person considers themselves to be when fantasising romantically, or when sexually attracted to someone.
8. Gender Identity:  Despite the increasingly widespread use of this term since 2000 it's never been satisfactorily defined.  A successful merging of gender role and sexual identity is perhaps the ideal outcome.

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.  

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 (Bruce Reimer) with a botched circumcision into living as a girl (Brenda) from age 17 months - medical studies changed the names and it became know as the "John/Joan" case.  Dr Money declared when Brenda was age 9 that the gender re-assignment was a complete success.  However this finding was undermined when Brenda grew up with a masculine gender identity anyway, and eventually decided to live as man, chosing the name David.  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.  

Boys raised as Girls
History is littered with cases of boys raised as a girl, or visa versa.  The practice is still quite common in some Asian countries e.g. the Metis of Nepal, the Aravani of India, the Hijras of South Asia, the Fa'afafine of Samoa.  A preference for male baby's has also led to many baby girls in China and India being raised as boys - in extreme cases they would otherwise face infanticide.

Whilst the practice is far rarer in the West, it does happen.  Dr Money and his colleagues may well have been influenced by encountering patients who had been bought up and now considered themselves to be of a gender that was different from their physical sex.

Meghan Fox with her stepsons. Their dress and appearance is often more typical of girls than boys.

A recent (2019) and high profile example is the actress Meghan Fox who is allegedly encouraging her three young step-sons to live as girls.  Meghan regularly posts photos of her sons wearing dresses, stating that "Noah started wearing dresses when he was two".  It's probably just fun for them pre-puberty, and the odds are that they will all grow up to be cis-men.

Sexual Identification of Transsexual Children
It is important to note that many boy-to-girl "transsexual's" do not consider themselves to be transsexual - indeed they often actively dislike being called such - they just consider themselves to be girls and in a medical context suffer from Gender Identity Disorder (GID) The reality is that young transgirls often associate the word "transsexual" with TV documentaries featuring strange balding middle-aged men, married with children, who at the end of the programme still look, sound and behave like men wearing wigs, dresses and too much makeup to their very discriminating eyes and standards.  Young transgirls simply cannot relate themselves with these examples of transsexuality - their problems are totally different, and even passing is rarely one of them.

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...

The results of an old study analysing the age at which transsexuals first sought medical treatment in Germany.  The exclusion of 18 and under is very notable.  It's very likely that a more recent study would show a dramatic shift towards 24 and younger.

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.

Riley (formerly Richard) "Grant", age ten, she never doubted that she was a girl and transitioned when age 7. (USA)  Source: Heidi Gutman/ABC

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). 

Jerke, a 10-year old transgirl.  (Holland)

If clinical testing finds that the following conditions apply:

1. onset of a desire to belong to the opposite sex before puberty

2. cross gender behaviour and social role without sexual arousal

3. dislike for one's own secondary sexual characteristics

then core transsexuality, commonly known as "true" or "primary" transsexuality, is likely to be confirmed and appropriate sex-reassignment treatment should be started. 

Nicole Roukema (Netherlands) was born Neils but knew that she was a girl by age 3.  She  transitioned age 13 and plans to have SRS surgery when 18.

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.

Suzannah Fleming, age 6 (inset) and now.  She started hormones age 12 with the brave assistance of her mother - a registered nurse.

Parents
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.

Danielle (formally Daniel) Gomez (Mexico/USA) had SRS at age 17, while still at High school.  Her supportive mother has written a book about Danielle's journey to womanhood.

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.

20 year old Rachel transitioned when 17, but still visits her parents as their son Daniel. (UK)

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."

For many years Amy (shown age 19) received psychiatric treatment to "cure" her gender dysphoria.

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.

Katie shown age 16 and while still in High School.  She transitioned when age 10 and her parents fought for her right to attend school as a girl.  Although on female hormones for many years, she was still waiting for her SRS in early 2003, age 19. (USA)

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 to worry.  
 

Young transsexuals such as Kelly benefit enormously from blockers and early use of female hormones, but some fundamental physical aspects remain. (UK)

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:

"Adolescents may be eligible for puberty-delaying hormones as soon as pubertal changes have begun. In order for the adolescent and his or her parents to make an informed decision about pubertal delay, it is recommended that the adolescent experience the onset of puberty in his or her biologic sex, at least to Tanner Stage Two."  [on average this means about age 11 for biologic females, age 12 for biologic males]  .....

"Adolescents may be eligible to begin masculinizing or feminizing hormone therapy as early as age 16, preferably with parental consent. In many countries 16-year olds are legal adults for medical decision making, and do not require parental consent. ....

"Any surgical intervention should not be carried out prior to adulthood, or prior to a real-life experience of at least two years in the gender role of the sex with which the adolescent identifies. The threshold of 18 should be seen as an eligibility criterion and not an indication in itself for active intervention."

A 16 year-old transgirl recovering from SRS - posted by her mother.  Allowing such radical surgery at this age is a hugely a controversial subject.

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.

Tom McGloan transitioned to Melanie McPryce (shown ages 15 and 18)

 

Puberty
Puberty can be defined as the biological developments which change boys and girls from physical immaturity to biological maturity.  For a transsexual child an inappropriate puberty sets a mountain that can never be full conquered, while an appropriate puberty offers a greatly eased path to a gender reassignment, both physically and psychologically.  

Laureen (formally James) Harries, age 27.  She transitioned when 19 and had SRS at 22.  She was a minor TV celebrity in the UK and is shown inset when 14.  Her life story is atypical for a young transsexual. (UK)

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."

Lauren Foster, nee Shipton.  She had SRS at age 18 and became a successful model (South Africa / USA)

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. 

Kelly at the start of her transition. (UK)

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.

How hormones affect a girls body during puberty (click graphic for large version)

A lot more information about puberty and its effects is given in the separate article here.
 
Body shape is controlled by oestrogen and testosterone.  During puberty, while boys are amassing bone and muscle thanks to their developed testes pumping out androgens (particularly testosterone), a high concentration of oestrogen in the female body results in the typical girl gaining nearly 35 pounds (15kg) of so-called reproductive fat deposited on the hips and thighs rather than on the waist.  Another female hormone, progesterone, also plays a significant and complementary role, most particularly in the development of breast tissue. 
 

Oestrogen levels in Women	Testosterone levels in Men
The changes in hormone levels at puberty are dramatically different between boys and girls, unsurprisingly this results in dramatically different physical changes.

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)

The Importance of Early Treatment
The treatment model developed for intersex children born with male testes but assigned as female is very relevant young transgender MTF children.  In order to maximise physical feminisation, low level oestrogen treatment of the young intersex girl begins at age 8-9 years.  Before the onset of a natural puberty a bilateral orchiectomy (castration) is performed age 11 to remove the testes and hormonal treatment is then increased (additional oestrogen, later supplemented with progesterone) to initiate a female type puberty.  

Nina (formerly Guido) transitioned at age 11.  She's is pictured nearly 3 years later, age 13. (Netherlands)

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 agonists or analogues (commonly known as 'puberty blockers') such as Goserelin Acetate (commercially sold as Zoladex) and Leuprolide Acetate (sold as Lupron).  These prevent or dramatically reduce gonadal hormone production, including testosterone, thus preventing the onset of the masculinising changes of adolescence.  The drug is usually delivered via a weekly or monthly subcutaneous injection into the abdomen.  While the treatment does nothing to directly 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.  As mentioned above, it's been discovered that some GnRH agonists help trigger a female puberty in a transgirl. 

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.

Cambell Kenneford.  Shown age 10, age 16 (when she transitioned and was about to begin hormones), and age 20 (after SRS).  (UK)

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. 

Vicky Nicole Eriksson (born Victor), pictured age 18.   (Sweden)   Riley, age 9

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.

Ashlyn Parram (born Lewis) was not allowed to sit an exam at her school because she was wearing a girl's uniform, including skirt.  The headmaster only relented after being shown the Equality Act 2010.  Shown age 11 and 16. (UK)

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?"

 

Photos from a medical article studying the effects of 18-24 months oestrogen treatment on teenage transgirls.  Patient 'A' (left) is age 19 and has transitioned.  Patient 'B' is much younger at age 15 and still pre-transition.  The study indicates the younger the patient (the youngest was 11) the greater the cis-typical physical feminisation, although the sample size below age 16 was small. 

 

Campbell Kenneford, shown age 16 and 22.  She was received no early medical treatment and had to deal with a male puberty before beginning female hormones age 16, she had SRS age 18. (UK)

Unfortunately, because of the John/Joan case, and mistakes made in the past when dealing with intersex children, recent medical studies have tended to emphasise the minority (about one quarter) of gender disordered children who don't eventually have SRS, and the disadvantages of early gender and sex-role re-assignment.  In particular, many advise against early genital surgery or irreversible feminising hormonal treatment.  But they neglect to consider why so many young transsexuals eventually have SRS despite the immense "corrective" pressures often exerted on them, nor do they consider whether those that don't have SRS would have perhaps enjoyed their lives more as a woman than they now are as a man.

Kristel (born Jeremy) age 11.

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 into 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.  

Ariel Nicholson posted on social media these photos of herself.  Clockwise from left: age c.4, age c.9, age 15, age 18.  (USA)

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". 

Jonas and Nicole Wyatt (USA)

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).

Teddy Quinlivan (USA).

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:

Since I transitioned when I was 16, I’ve been living as a cis female.  I was very lucky, because I won the genetic lottery – I looked a certain way and my voice hadn’t dropped.  That privilege gave me a lot of confidence to walk down the street, date, and (work) in the fashion industry, where people would presume I was a “normal” girl.’ 

I actually started taking hormones when I was 17. But transitioning isn’t just a matter of growing out your hair, wearing heels, and piercing your ears. Taking hormones affects your mood; it’s like being born again. It changes not only the way you look but the way you see the world. While my career was taking off—I was signed when I was 22—I was going through a lot emotionally. All of a sudden, I was acting like a prepubescent girl. And since I was concealing my identity, no one understood.

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, she started at a new school where the headmaster was sympathetic and agreed to let her register and attend 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."

Shown age 45, Anna Taylor transitioned at 11 and began hormones at 13 after her parents found a Dutch doctor willing to prescribe them.  Surgeons refused to perform her SRS until she was 18, she had surgery three days after her 18th birthday. (UK)

Early transition and the commencement of gender confirmation hormone treatment will permit the transsexual boy-to-girl a female childhood, and visually a near normal female puberty.  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.

Jasmijn age 9 (born as Colin).  During a summer vacation her family chose her new name. (UK)

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." 

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.  

Angel (formerly Oliver) Wheadon began taking her Mum's HRT pills at 9, transitioned at 12 (shown left at 13), was prescribed oestrogen hormones at 14, had SRS at 17, and is shown right age 21. (UK)

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. 

Amanda Lear may have started hormones at 15 - depending what birth date you accept.  (Born in Vietnam, lives in France, UK passport!)

For example a 2021 study claimed that the development of hip bone geometry during gender-affirming hormone therapy in transgender adolescents resembles that of the target gender if hormone treatment is started in early puberty.  The details of the study are not fully supportive of this headline but do suggest that a transgirl starting hormones by age 14 is likely to have after puberty a pelvic girdle half way between male and female averages.

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. 

Two transgirls in their late teens. (Left) 18-year-old April after two years of hormone treatment, no surgery. (Right) Another photo of Terry in 2003, now transitioned, age 19.

Teenage transgirl Terry on holiday, although pre-transition the effects  effects of her hormone treatment are obvious.  (UK)

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 individual's 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.

GnRHa pubertal induction

After legal debate Johanna (formally Johannes) Bulow was allowed puberty blocking drugs at age 12 and female hormones at 13.  She's shown age 14, and (inset) age 15 holding her new identity papers. (Germany)

An important development since 2000 is the discovery that gonadotrophin-releasing hormone agonists (GnRHa) such as Leuprolide (sold as Lupron) can help trigger the onset of a female puberty in transgirls when combined with estrogen hormone therapy, usually Estradiol.  As a "puberty pulse" generator it's typically taken as an intramuscular injection every six months - as few as two injections may be prescribed.  The resulting visual body feminisation is significantly greater than from estrogen alone.

Results

The 2020 paper Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction With Attention for Sexual Function and Satisfaction, by T'Sjoen G, Arcelus J, De Vries ALC, Fisher AD, Nieder TO, Özer M, et al..  This essentially is a collation of many small medical studies, and it identifies the following key results in transgirls taking gender confirmation medication:

• In a group of very young transgirls (n= 49, median age 13.6), puberty blockers alone resulted in weight, fat mass and BMI increasing and lean body mass such as muscle decreasing in the first year of treatment.

• In late-pubertal adolescents, taking progesterone (e.g. lynestrenol) accentuates the effects of low level of natural estrogen production in the body of a transgirl.  A study of 21 transgirls treated this way for a mean duration of just less than 1 year, found a significant loss of lean mass (-2.2 kg), a gain of fat mass (+1.5 kg) and decreased grip strength

  A transgender group meeting at a university - in recent years "Transgendered" has finally been added to Gay, Lesbian & Bisexual.

• A study of 14 transgirls (mean age 16.3) on hormone therapy found that they had higher body fat (28% 6% vs 20% 10%) and lower lean mass than cis boys (69% 5% vs 77% 9%

• A study of 22 transgirls who taking estrogen (estrodial) combined with GnRHa pubertal induction found that obvious breast development started in 3 months in 83% of participants, and after 3 years an extraordinary 86% had a Tanner breast stage 4 to 5.  Hip circumference also increased and waist-to-hip ratio decreased.

• 71 transgirls who began gender affirmation hormone therapy by age 16 were re-examined age 22.  Their total body fat had increased by 10%, lean body mass decreased by 10%, and the waist-to-hip ratio decreased (i.e., the waist was relatively smaller)

A cartoon from the 1970's that is still relevant

An obvious gap in medical literature is the lack of any studies comparing the pubertal development of 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.

The Skeleton
Anecdotal evidence is that reduction in levels of "male" androgen hormones caused by oestrogen treatment has a slight effect on the skeleton - reducing male type rugged'isation and enhancing female type features, for example slightly broadening the pelvis and helping reduce the girl's adult height (by perhaps an inch or two) compared with if she had experienced a male puberty.  However, while hormones play an important role in post-pubertal body shape, it seems that the male "Y" chromosome is dominates skeletal growth in a transgirl, she will thus still experience some a degree of skeletal masculinisation, even if she commences female hormone treatment at 11 or 12.  In general, her physical characteristics as determined by her skeleton (height, skull, hand & feet size) will lie between the male and female norms post-puberty - although more towards the former than the later.  This not necessarily bad as the western idea of feminine beauty is for tall and leggy women.  As an adult, the woman will typically be both tall compared to the average woman (67½" vs. 64¼") and have long legs - both absolutely (32½" vs. 30") and relative for her height, ideal for those girls with ambitions as a model!  [For more information about average male and female body sizes, see the article on this site]

"Lucy Parker is a typical teenage girl, obsessed with clothes, boys, make-up and shopping."   Lucy (formerly Richard) transitioned at 16 and a BBC documentary followed her having breast augmentation just days after her 18th birthday allowed this. (UK)

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. 

The same technique can theoretically be used to help induce in a young transsexual girl a final height of 63" - 69" - typical for a Western European woman in the early 21st century. However, obtaining supervised treatment to restrict the height of a transsexual boy-to-girl to female norms is very difficult as  height is not considered to be a disease.  Endocrinologists are 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. 

Breaking all the guidelines Marilia (formerly Errolclaud) Gabriela started hormones at age 13.  She had SRS at 22. (Brazil).

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 future study of transgirl's and transboy's may lead to some important results.

 

Kim Petras

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 off his "thing", for the sake of a normal life his parents increasingly accepted their son Tim as being their daughter Kim.

Kim Petras age 13.  Born in August 1992, in 2008 she became famous as the world's youngest post-SRS transsexual at age 16. (Germany)

The situation reached a crisis when age 11 Kim grew increasingly distressed at the prospect of becoming like other adult transsexuals "with big hands and deep voices", whom she thought looked ridiculous when they dressed 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 and even 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".

Kim Petras, age 21

Dr Achim Wuesthof, who for many years treated Kim at his 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, with considerable success.

Part 2 of "Treatment of YoungTranssexuals"....