A child assigned male at birth began confounding parents, family and neighbors at age 3 by repeatedly declaring and insisting, "I am a girl." After lengthy consultation with gender specialists, the child was eventually diagnosed with what once was called "gender-identity disorder of children" but is known in today's psychiatric manual, DSM-5, as "gender dysphoria in children." Now the child, 12 years old and approaching male puberty, is terrified about the prospect of impending body changes.
Gender dysphoria (GD) in children is a rare condition, and there has been thoughtful professional controversy about how to treat prepubescent children so diagnosed. However, there is little controversy among acknowledged experts about what to do for gender-dysphoric children when the onset of puberty, with its unwanted secondary sex characteristics, looms large.
This is because some gender-dysphoric children assigned male at birth become anxious, panicky and even suicidal at the prospect of developing facial hair and an Adam's apple. Similarly, gender-dysphoric children assigned female at birth fear developing breasts or the beginning of menses. Though it may not be clear at this stage of development whether a child's GD will soon resolve itself or continue into adulthood, in gender clinics around the world, the recommended treatment for either child is puberty suppression.
Although gender reassignment for adults first began in the 1920s, puberty suppression for gender-dysphoric adolescents has only been around since the late 1990s. The Center of Expertise on Gender Dysphoria at Amsterdam's VU University pioneered this approach, and their recent online publication of a longitudinal study in the journal Pediatrics offers insights into how some of these kids fare.
Their protocol uses gonadotropin-releasing hormone analogs in the first stages of puberty to block normal hormones that would cause children to develop secondary sex characteristics. Puberty suppression usually is started at age 12, and the clinical decision to initiate treatment is done with great deliberation. Those treated get a comprehensive psychological evaluation over a long period of time.
Puberty suppression is also considered reversible. The medications are discontinued if the adolescent's GD spontaneously desists. In those cases, the adolescent will undergo normal puberty, albeit a delayed one. However, in cases where GD persists, cross-sex hormones (masculinizing or feminizing, depending on the sex assigned at birth) are first administered at age 16, and gender-reassignment surgery may be performed later, at age 18.
In their study, Dr. Annelou de Vries and her colleagues report on 55 young transgender adults, including 22 trans women (male to female) and 33 trans men (female to male) who had puberty suppressed as adolescents. All were assessed three times over six years: before starting puberty suppression, at the time that cross-sex hormones were introduced, and at least one year after gender-reassignment surgery. The researchers assessed psychological adjustment and "measures [of] objective and subjective well-being (often referred to as "quality of life"), that is, the individuals' social life circumstances and their perceptions of satisfaction with life and happiness." The study did not address any physical side effects of treatment, although the authors note that those studies are in the works.
Over the study's six-year course, all the young adults were satisfied with their physical appearances, and none of them showed any regrets about transition. The researchers found that "GD was alleviated and psychological functioning had steadily improved. Wellbeing was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being." Although both trans men and trans women appear to have benefited from the clinical approach, trans women showed more improvement in body-image satisfaction and psychological functioning.
Significantly, the researchers believe that early medical intervention was not the only factor determining a successful outcome. They also credit a "comprehensive multidisciplinary approach" and "a supportive environment" as vital to helping these youngsters.
Some socially conservative psychiatrists have criticized the use of puberty suppression, even calling it a form of "child abuse." It seems unlikely that these new research findings will dispel their ideological perspectives. Nevertheless, further studies are certainly warranted. They may not only change more minds but offer greater hope for transgender adolescents in the future.