Q&A: Doctors on Puberty-Delaying Treatments

A small group of doctors around the world have introduced a controversial approach to the treatment of preteens and teenagers who believe they are the opposite sex.

Right before puberty begins, they prescribe children hormone-blocking medication. This allows the child to continue growing without developing physical characteristics such as breasts, facial hair or Adam's apples. Later, the child can elect to resume their natural puberty development or can begin a gender transition by taking the sex hormones of the opposite sex.

Researchers in the Netherlands pioneered this treatment. Its prevalence in the United States is unclear, because most physicians using this approach keep it secretive. NPR talked with two doctors about the treatment's benefits and risks: one who practices it in the United States and another from the United Kingdom, where the treatment is not practiced by the National Health Service.

Dr. Norman Spack

Spack is an endocrinologist at Children's Hospital in Boston. He has worked with transgender adults for over 20 years and was one of the first doctors in the country to offer hormone-blocking treatments to teens.

How many patients do you have on this treatment?

About 10 people are now on the treatment, but we hear from one or two new people a week for some kind of service.

How confident are you that you can identify a kid who will become a transgender person as an adult?

It's a very good question. My confidence comes partly because I've yet to see one change their mind and partly because we're using the psychological testing methods the Dutch have perfected, and they've yet to see one person change their mind. And they've run 100 kids through the treatment.

What physically happens to a child who undergoes treatment?

Ultimately, in a girl it blocks her ability to make estrogen. That means her breasts will not grow. The uterus lining will not get built up enough to ever flow, and because growth plates stay open, it allows a girl to grow for four more years. So genetic females have potential to get height [closer to a male height].

For boys, it prevents body hair, facial hair, Adam's apple. And remember, hair, along with aspects of the skeleton, can never be reversed. If a person goes all the way through puberty and develops facial hair, [he or she] will spend, on average, $120,000 in their lifetime on electrolysis.

How long do you use the hormone blockers to suppress puberty?

Until around 16. Then you use the cross hormones to bring on the characteristics of the opposite sex. And remember, if you just stop the hormone blockers at 16, the person will go right back to genetic puberty within months. So the beauty of the suppressant is not as a treatment but for prolonging the evaluation phase ... 'til a young person has greater ability for abstract reasoning. It buys you time without a tremendous fear of their body getting out of control.

And the treatment can really enable them to look like a person of the opposite sex?

Well, that's what the Dutch have shown. It's quite amazing.

Talk to me about how transgender kids experience puberty.

In the cases of people we see, they are horrified. It's a very risky time; many attempt self harm. The development of the first period in someone who thinks they're a boy — you can only imagine.

So do groups say you should not do this treatment?

There's been very little criticism. If anything, it's been totally opposite to what I expected. Transgender people have written in saying, 'Thank God for you. Now another generation won't have to suffer.'

[Transgender people are] a group of people who historically have been among the most unhappy in the world — and in some cases the most poorly accepted. Now I think we can make them happy, and the Dutch have shown that they can fit in — in the way they want to. And I think we owe it to them.

Dr. Polly Carmichael

Carmichael is a psychologist at the Portman Clinic in London, where national guidelines say hormonal treatment of transgender teenagers should take place only after puberty. Carmichael has worked with dozens of kids with gender identity issues. In 2000, the Portman Clinic, which specializes in gender issues, published a study of all the children treated at the clinic who had been diagnosed with gender identity disorders. There were 124 children in all.

I understand that you have done a study of all 124 children who have gone through your clinic, and that 80 percent of those under 12 chose not to pursue sexual reassignment as adults. The kids who didn't continue — what were their reasons?

It's very tempting to be looking for similarities that might predict it, but there's a very wide range. I can think of one [boy] who came first at 6 or 7 and we saw on a regular basis. And over that time, he felt more comfortable being the sort of boy he was: having female friends, being very theatrical. At first, he really wanted to wear pink — and the mother was torn between wanting her child to choose his own clothes and the teasing. That changed, and at a later stage he said he just felt OK as he was — that he still sometimes had those feelings, but he felt happy being a boy. And that's how he wanted to continue.

I wouldn't say it's impossible to identify individuals [who] will go ahead with sex reassignment. Clearly, the Dutch have an assessment battery that they feel is quite accurate at identifying them at an earlier stage. But I think there's a lot of flexibility.

Do you have reservations about identifying kids under 12 as transgender?

I think some of the children under 12, as well as over, would fulfill diagnostic criteria for transgenderism. But I would say, in general, my experience is that in younger age groups there is greater flexibility, and the figures support that.

How do you feel about giving hormone treatments to young transgender individuals?

There are debates to be had around the impact of giving hormone blockers at an early stage. One of the debates is, indeed, does one's own sex hormones have an impact on identity development in adolescence? So if one intervenes, is that affecting the final outcome? I think that's just one part of the debate, but important to debate.

What we're doing now is new, so it's appropriate to be exploring and discussing. And it's a plausible question — is one of the effects a change in final outcome?

There's not evidence, though. It's just a question?

I don't know where you'd get that evidence from, really. It's relatively new treatment, so in general individuals have been exposed to their own sex hormones — and some will go on to be transgender, some not. It's more important to have a debate.

Have you been around transgender children going through puberty?

I have been around them, kids up to 16 to 18. It's exceedingly distressing for many of them. If you have a strong conviction that you are in the wrong body, then to feel your body developing in an alien way is extremely distressing. Often, what individuals seek to do is avoid any contact or thought of their sexual characteristics. For instance, girls bind their breasts in part because they're presenting as male outside, but also because they just don't want to see themselves. And for adolescent boys, they wouldn't want to look at their penis, they would find that incredibly distressing and would wee sitting down or would always shower wearing underpants.

When you see that, does it seem cruel to not allow children to have hormonal therapy?

It's a really hard question. Obviously, in working with families, one is trying to ameliorate distress. It's important to remember these are very complex cases; gender disorder is part of a complex presentation.

Why haven't Netherlands researchers had any kids who decided transitioning was a mistake?

Because I think they've selected that group. They identify individuals through a battery, a group who they feel would go on and seek sex reassignment. So it's very positive. But they're a selected group. One of the Dutch criteria is a stable biological background, and certainly many of the children we see wouldn't fulfill that criterion in that they're not psychologically stable.

Is it immoral to give 10-year-olds hormone blockers?

My personal view is no, I don't think it's immoral, but my personal view isn't relevant, really. The arguments are complex, and what's not helpful is to have a very polarized debate, because that's not the issue. It creates a lot of distress among gender identity-disordered individuals who feel strongly that they want treatment. But it's important to have a proper debate.

The tragedy is we all want the same thing: We want to do our very best to support individuals to do what's right for them in the long term and short term. The problem is, managing anxiety in the short term is very difficult. Suddenly something comes along and offers a solution, and I know families have gone to America to seek treatment. It's horrible to be cast as withholding something that's the solution to everything. But we have to keep the bigger picture in mind, think long term, and develop an approach based on evidence.

Answers edited for content and clarity.