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Girl/Boy Interrupted 

A new treatment for transgender kids puts puberty on hold so that they won't develop into their biological sex

Wednesday, Jul 11 2007
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With continued counseling, and after having lived for a period as the target gender, both sexes are eligible for surgery at age 18 to remove the testes or ovaries. After that, they stop the GnRH blocker.

Not all countries have such easy access. Hormonal intervention must be approved in court in some countries, and with Lupron costing roughly $500 to $700 a month in the United States, the treatment is out of reach for many families. Some doctors report getting payment from insurance by playing with the wording in the diagnosis — leaving the word "transgender" out — but many others have run into a brick wall with third-party payers, raising concerns in the transgender community that the treatment could create a class division between those who can and can't access treatment.

Without the luxury of delaying puberty with Lupron, some doctors go straight to prescribing cross-sex hormones to kids as young as 12 or 13 to override their natural puberty and allow them to develop as the target sex at the same time as their peers. Cross-sex hormones can cost as little as $25 to $70 a month, a fraction of the cost of Lupron, but many of the changes are permanent.

"Most [adolescents] don't want to just suppress. They want to move," says Marvin Belzer, an adolescent medicine specialist who has started young teens on cross-sex hormones at Childrens Hospital Los Angeles. "In our society in America, starting early has far less bad consequences than starting late."

But not all are convinced starting early is best. The team at the Gender Identity Development Service at the Tavistock Clinic in London will not intervene until puberty is nearly complete, saying the experience may help patients make a more informed decision about being misplaced in their body. Domenico Di Ceglie, the team's child and adolescent psychiatrist, wrote in an e-mail that 20 percent of the adolescents treated in the clinic no longer wanted any intervention once they'd completed puberty.

He warns that the long-term effects of delaying puberty are unknown. He questions whether the puberty-blocking treatment itself could affect a patient's gender identity, since adolescence is a key time for brain development and a possible time for a change in perceived gender.

Then there's the question of bone density: The London team questions whether delaying puberty could cause a long-term deficiency, since bone accrues at a rapid rate with the hormonal flurry of adolescence. The Dutch say their patients' bone density catches up to normal once they begin cross-hormones, but patients will be monitored until age 25 to see if there are any final differences.

The two teams plan to compare their outcomes in follow-up studies, but they agree on one principle: With studies showing anywhere from 75 to nearly 90 percent of children with gender-variant behavior will eventually be comfortable with their biological sex, tight screening is key.

The younger the patient, the more likely that the child will change his or her mind, says Ken Zucker, a psychologist who has treated 500 gender-variant children and serves as head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto.

"I just haven't seen these kids where at age 10 I'm convinced that this is the way they're going to be." Zucker says. "Doing this type of endocrine treatment seems pretty cool, but it tends to ignore the possibility that psychological therapies can help kids resolve their gender identity confusion."

So it comes down to an ethical dilemma of choosing the lesser evil: wrongly suppressing puberty in kids who will grow out of their gender variance or refusing treatment to all. Peter Lee, a professor of pediatrics at Penn State College of Medicine who has treated three young transgender teens with Lupron, knows on which side he'd rather err. Twenty years ago, a biological female who identified as male came to him in late adolescence with "so much pain and agony with her development in the wrong direction" that she later committed suicide.

"So you're balancing that against the risk [of wrongly putting someone on Lupron]," Dr. Lee says, because with Lupron, "sooner or later in this realm, if you deal with enough individuals, you will make a mistake, and will have judged incorrectly."

Few of the transgender adults interviewed for this story said they had the consciousness at such a young age to know what transgender was in the days before Internet communities and Oprah specials, let alone that they would assume this identity. While many concede that kids who receive this treatment will have an easier time in puberty and passing in the years beyond, some question how transitioning so early will change a community where having lived on both sides of the gender line is part of a collective identity.

After living 17 years as a male, followed by years of hormones to transition, Alexis Rivera of the Transgender Law Center says she decided to go off hormones and settle into a space somewhere between male and female, and now at 29, has proudly done so.

"If medical technology keeps advancing, are we going to eradicate transgenderism?" Rivera asks. "The younger the transition starts, the younger you start socializing a biological female as a boy, they're not going to have that transgender identity. They're not going to have to walk this earth as their genetic sex."


Juan struts across the parking lot with the lumbering gait of a macho guy in training, with an eighth-grade graduation gown flung over his shoulder and a rhinestone glistening in one ear. He slaps five and curls fingers with a friend and then hugs a pretty classmate in heels who poses over Juan's shoulder so his mom can snap a photo.

About The Author

Lauren Smiley

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