Endocrine Society Issues Guidelines for Transgender Children

A transgender individual is someone whose gender identity or subjective sense of what sex they are differs from the legal sex that was assigned them at birth. Some transgender individuals have identifiable physical syndromes that result in ambiguous sex characteristics, while others simply live their lives feeling that they are the opposite gender from what people think they are. This sense often begins in childhood, though some individuals wait until late in adulthood to choose to make the transition to the sex that fits their experience.

Once a young person has matured physically and acquired the secondary sex characteristics of their birth sex it is much more difficult to transition. Thus a person with male anatomical features whose voice changes, whose body shape becomes that of a man, whose body is covered with hair, will have a much more difficult time if they are ever to live as a woman. It is possible to intervene medically, to administer hormones that will delay or prevent the onset of puberty, which would ease the transition. But you're talking about a kid here, and a lot of people are uneasy about interfering with what appears to be a natural process, even if intervention would make the person's life happier and more satisfying in the long run. Adults are always concerned that the child is "going through a phase" that will pass, and may be hesitant to initiate procedures that will have permanent impact. Plus, there are a lot of people who are eager to pass judgment on anyone whose sexual orientation or gender identity varies from the majority.

From the LA TImes:

The nation's oldest and largest organization of endocrinologists has recommended that physicians treating children with gender identity disorder intervene to delay puberty at its first signs and wait until a child is at least 16 before offering hormonal therapy that would begin his or her gender transition.

In a new clinical practice guideline unveiled today, the Endocrine Society tackled some of the most ethically sensitive decisions endocrinologists face in the treatment of those who are born of one gender, but identify themselves strongly with the opposite gender. Indeed, the society urges that its physicians rely on a mental health professional to render a diagnosis of transsexualism, which is termed gender identity disorder in the psychiatric profession's current diagnostic manual.

The new practice guidelines also recommend that no action be taken to intervene in the hormonal balance of a young child who identifies as the opposite gender of his or her birth. "A diagnosis of transsexualism in a child who has not gone through puberty cannot be made with certainty," the group concluded.

At the first signs of puberty, however, the new guidelines recommend that physicians use hormone therapy strictly for the purpose of suppressing pubertal changes until an adolescent has reached the age of 16. At that point, the group concluded, "cross-sex hormones may be given." Treating transsexual kids: wait for, then delay puberty to treat

Seems like these days puberty starts hitting around eleven or twelve years old, sometimes younger. Plain old puberty is confusing enough to a kid that young, your body's changing but you still feel like a kid, and then to experience yourself being swept along with a falsehood about what sex you are, who you are really, that's got to be very difficult. A kid that age may not be ready to make decisions that will affect their entire future. So it sounds like a good idea to wait until they are sixteen, they ought to have some sense of who they are by that age.

Those guidelines come at a time when many of those with "gender dysphoria"--persistent distress over one's gender at birth--are asking to begin gender reassignment hormonal therapy and/or surgery at an earlier and earlier age. While surgeons have been reluctant to do gender reassignment surgery on a patient under 18, endocrinologists often face pressure from would-be transsexuals to offer earlier, interim treatment. The new guidelines are likely to set a standard that many endocrinologists will follow in such cases.

"Transsexual persons experiencing the confusion and stress associated with feeling 'trapped' in the wrong body look to endocrinologists for treatment that can bring relief and resolution to their profound discomfort," said Dr. Wylie Hembree, a Columbia University endocrinologist who chaired the committee drafting the guidelines. The new guidelines, he added in a news release, are intended to provide "science-based recommendations" for practitioners to provide "safe and effective treatment" to those diagnosed with Gender Identity Disorder.

Oddly, some members of our community use the DSM category "Gender Identity Disorder" to argue that transgender people are sick, or mentally ill. Really the diagnosis only identifies individuals who might live better after they transition to the opposite sex. Still, some bad-hearted people will try to smear transgender individuals with the stigma of mental illness, I guess it makes them feel better about their own lives.

The transgender community has advocated for changes in the psychiatry's approach to the diagnosis of gender identity disorder, which is now being revisited in drafting sessions for the profession's diagnostic manual. Among the transgender community's concerns: that current definitions of Gender Identity Disorder lump the diagnosis under "paraphilias," contribute to stigmatization, and fail to support the goals of gender transition and access to surgical and hormonal therapies in treatment of GID.

The new practice guidelines are published in the September issue of the Endocrine Society's Journal of Clinical Endocrinology & Metabolism. For a somewhat dated discussion of the ethical issues involved, check out this article from Salon. And if you feel you were born into a body of the wrong gender, here's a place to seek help and support.

These decisions are bound to be controversial. On one hand these doctors are talking about treating a straightforward, if complex, condition; on the other hand, the treatment is nested within the norms of a society that has strict prohibitions on gender behavior, and makes harsh judgments of individuals who violate those prohibitions. While it will be impossible, and probably not even desirable, for physicians to outline treatment without acknowledging social norms, in the end the patient's best interests must be kept in mind, regardless of what others think.