Drug treatments for transgender kids pose difficult choices for parents, doctors

May 19, 2012

While no one knows how many American children have gender identity disorder, increasing numbers are being treated for a condition long ignored or denied by parents and pediatricians.

“There’s no question that everybody is seeing more of this now,” said Norman Spack, the director of one of the nation’s first gender identity medical clinics at Children’s Hospital Boston.

And as awareness grows, so does the controversy surrounding the next possible steps in gender transition — first treatments to suspend puberty, then a rare and radical course of hormone injections to slowly grow a teen’s body into its opposite gender. The hormone injections, which begin at about 16, make the child sterile.

The ethics of that kind of medical intervention are the subject of debate because, as New York psychiatrist Jack Drescher noted in a recent article in the Journal of Homosexuality, “children have limited capacity to participate in decision making regarding their own treatment, and even adolescents have no legal ability to provide informed consent.”

As a result, wrote Drescher and his co-
author, William Byne, children “depend on parents or other caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term.”

Even Spack, a pediatric endocrinologist who champions early gender transitions and who has pioneered the use of hormone injections, acknowledges that only a handful of patients and their parents have chosen to go that route.

“This is heavy-duty stuff for a 16-year-old,” he said. But for those in “horrendous psychological shape,” who are deeply depressed, self-
mutilating or suicidal, it can be the key to survival, he argued.

Spack said he gets calls almost daily from hospitals and pediatricians all over the country asking about treatment. But the vast majority are seeking information on puberty blockers, already in wide use for children experiencing premature puberty.

The puberty blockers are given to transgender girls who are 10 to 12 years old to keep their bodies from maturing and menstruating. Boys receive them from 12 to 14 to stave off a flood of testosterone.

Suspending puberty gives the kids more time to decide who they are and whether switching genders is the answer to their problems, psychiatrists say. The effects of puberty blockers are reversible if the treatments are halted. Spack has treated about 140 kids this way in Boston.

The hormone injections — a far more extreme option — are designed to make sex-change surgery less painful and expensive for young adults.

Spack’s most renowned patient, Jackie Green, just became a finalist in the Miss England pageant. Spack began treating her when she was 12. Four years later, she was so certain about being transgender, she had sex-change surgery in Thailand on her 16th birthday.

Most doctors and hospitals don’t offer the controversial hormone injections, and not just because they lead to sterility. What little research has been done suggests that most children who have gender dysphoria — a persistent discomfort with one’s gender and the key symptom of gender identity disorder — eventually outgrow it, said Margaret Moon, a bioethicist and pediatrician at the Johns Hopkins School of Medicine.

One of the few studies, done in Amsterdam over the course of a decade, followed 77 children — mostly girls — who came to the VU University’s department of psychology and neurosciences because they’d received a diagnosis of gender dysphoria. About 10 years later, 27 percent of them were still gender dysphoric and went on to live as transgender adults, 43 percent said they weren’t and the rest didn’t respond or couldn’t be located.

“Most children with gender dysphoria will not remain gender dysphoric after puberty,” the researchers concluded.

That jibes with what Edgardo Menvielle, who been treating transgender kids at Children’s National Medical Center in D.C. for about a decade, has seen among his patients. About 80 percent switch back to the biology they were born with. The other 20 percent remain transgender into adulthood.

Petula is a columnist for The Washington Post's local team who writes about homeless shelters, gun control, high heels, high school choirs, the politics of parenting, jails, abortion clinics, mayors, modern families, strip clubs and gas prices, among other things.
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