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    Are children too young to be transgender?

    When we hear the word transgender, we typically think of a grown adult who probably has taken medical approaches to feel comfortable in their own body. When we think of children doing the same thing, it’s incomprehensible. How can a child decide they want to change genders, take hormones, and have surgery? 

    Defining Transgender

    The term “Transgender” describes someone whose gender is incongruent with the sex they were assigned at birth. 

    Transgender is often conflated with having undergone surgery and hormone treatments, and the individual can only call themselves transgender if they have medically transitioned.

    Being transgender does not automatically mean the individual is going to or had medically transitioned. Some trans people go on hormones and undergo surgeries, and some do not. It just means they do not identify with the gender they were assigned at birth

    Defining Transitioning

    Transitioning is a broad term used to describe the different ways a person may go about affirming their gender.

    Social transitioning:

    Expressing one’s gender identity

    • Changing one’s name
    • Changing one’s pronouns
    • Changing one’s clothes
    • Changing one’s hairstyle

    Medical transitioning:

    Taking a medical approach to alleviate dysphoria.

    • Hormonal Transition
      • Undergoing Hormone Replacement Therapy to alleviate dysphoria and/or elevate euphoria
    • Surgical Transition
      • Undergoing under one or multiple surgeries to alleviate dysphoria and/or elevate euphoria

    Legal transitioning:

    Changing one’s legal documents to match their gender identity.

    • Birth certificate
    • Drivers license/ State ID
    • Social Security
    • Passport

    Transgender children only socially transition.

    Once the child has gotten to the age of puberty, they may start that conversation with their parent and doctor about beginning medical intervention.

    Early childhood Gender development

    A common question asked is “How old can a kid know they’re trans?” 

    Early childhood development experts say around the ages of 2-3 years old is when a child can express their gender identity. Once they learn how to talk, they can express themselves.

    • 6 Months: Child can hear the stereotypical voice differences between men and women

    • 10 Months: Child is able to form stereotypical associations between faces of women and men

    • 18-24 Months: Children begin to develop a sense of gender by the patterns they are surrounded by.

    • 2 Years: A child may be able to express a gender, or can define physical differences in bodies

    • 3 Years: A child can define themselves as a boy or girl (or other genders)

    • 4 Years: Most children have a stable sense of their gender identity.

    • 5 Years: Child may start developing strict gender binaries and stereotypes 
    1. “Children and Gender Identity: Supporting Your Child.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 1 Sept. 2017, www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/children-and-gender-identity/art-20266811

    2.  Rafferty, Jason. “Gender Identity Development in Children.” HealthyChildren.org, American Academy of Pediatrics , 18 Sept. 2018, www.healthychildren.org/English/ages-stages/gradeschool/Pages/Gender-Identity-and-Gender-Confusion-In-Children.aspx?fbclid=IwAR3NX8CmjDoxL35ACf_rqAY6Ltvr44xz_KiAj-g42CR4lImchCYeJMR5Qr8.

    3. “Healthy Gender Development and Young Children A Guide for Early Childhood Programs and Professionals.University of Washington, Early Childhood Learning & Knowledge Center, U.S. Department of Health and Human Services, Administration for Children and Families, 6 May 2020, depts.washington.edu/dbpeds/healthy-gender-development.pdf.

    4. Martin, C. L., & Ruble, D. N. (2010). Patterns of gender development. Annual review of psychology61, 353–381. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747736/

    5. “Gender Identity.” Gender Identity – Caring for Kids, Canadian Paediatric Society, May 2018, www.caringforkids.cps.ca/handouts/gender-identity.

    6. Hawkins, Linda A. “When Do Children Develop Their Gender Identity?” Children’s Hospital of Philadelphia, The Children’s Hospital of Philadelphia, 16 Jan. 2018, www.chop.edu/news/health-tip/when-do-children-develop-their-gender-identity.

    Diagnosing children

    Some transgender children may be diagnosed with Gender Dysphoria by the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

    Gender Dysphoria is described as a general descriptive term refers to an individual’s affective/cognitive discontent with the assigned gender. Refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender, but is more specifically defined when used as a diagnostic category. 

    Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) American Psychiatric Association, 2013,  Gender Dysphoria; Page 451. https://cdn.website-editor.net/30f11123991548a0af708722d458e476/files/uploaded/DSM%2520V.pdf

    “A: In children, gender dysphoria diagnosis involves at least six of the following and an associated significant distress or impairment in function, lasting at least six months:

     

    1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).

       

    2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.

       

    3. A strong preference for cross-gender roles in make-believe play or fantasy play.

       

    4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

       

    5. A strong preference for playmates of the other gender.

       

    6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.

       

    7. A strong dislike of one’s sexual anatomy.

       

    8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
    B: The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.”

    Parekh, Ranna M.D., M.P.H. What Is Gender Dysphoria? American Psychiatric Association, Feb. 2016, www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

    Children will only be diagnosed with Gender Dysphoria if a trained professional sees fit and the child experiences 6 out of the 8 criteria for longer than 6 months

    1) Insisting they are or wishing to be another gender. Correcting someone they feel misgendered.

    Example: If a parent introduces their AMAB child as their son, and the child says “No, I’m your daughter.” and becomes upset when they are not being called “daughter”  or say things like “I a girl”

    2) Only wanting to wear stereotypical masculine/feminine clothing. Resisting clothing typical of their assigned gender

    Example: A child assigned female may become dysregulated, distressed each time a parent puts a dress on them. Consistently picks out clothes typically worn by boys.

    3) While playing make-believe games, they are usually expressing a gender that is not what they were assigned at birth.

    Example: A child assigned male may pretend to be a “princess” or “queen” or “mommy” roles.

    4) Only wanting to play with toys stereotypical of another gender

    Example: A child assigned male at birth only wanting to play with dolls

    5) Rather have friends or play with another gender and only another gender

    Example: A child assigned female is only wanting to play with boys or most of their friends are boys.

    6) Rejecting stereotypical toys of their assigned gender and only playing with toys that are stereotypical of another gender.

    Example: A child assigned female crying and throwing a barbie doll they got for a birthday present 

    7) Not liking or hating one’s genitals, wanting to hide them, attempting or committing self harm on the genitalia

    Example: A child assigned male cries to their parents about wanting to get rid of their penis.

    8) Wanting to go through the puberty typical of another gender

    Example: A child assigned male at birth asking when they will grow breasts or wants a bra with excitement

    Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) American Psychiatric Association, 2013,  Gender Dysphoria; Page 452.
    https://cdn.website-editor.net/30f11123991548a0af708722d458e476/files/uploaded/DSM%2520V.pdf

    How do trans children transition?

    Social Transitioning

    Social transitioning may look different for every family depending on how much support they receive in the community and of course how the child feels as well. 
    _______________

    Transitioning is not something that happens over night, and tends to be a slow process over several months to years. Every one is different
    _______________

    A 5 year old questioning their gender may have a different process of transitioning than a 5 year old who has severe dysphoria and is persistent about their gender identity.

    It is not uncommon for children to start wearing the clothes they prefer at home first for a few months/years.  

    Once comfortable enough, they may start coming out to the public, wearing their preferred clothes all the time, including school.

    They also may start using a different name and pronoun set. Some kids may try out a few names to see what fits the best. 

    Once comfortable enough, they may start coming out to the public, introducing themselves with their new name, and having their birthname no longer being used in school. 

    Hormone Blockers

    What are hormone blockers?

    Hormone blockers, also called puberty blockers, blockers or puberty suppressants, are a gonadotropin-releasing hormone (GnRH) antagonistic, preventing the secretion of: 

    • Follicle-Stimulating Hormone (FSH)
      • What makes body hair grow
    • Luteinizing Hormone (LH),
      • preventing the secretion of sex hormones, like estrogen and testosterone.
    It pauses puberty in it’s tracks, stopping any further pubescent changes from taking place until the child is ready.

    Bowen, Richard, DVM, PhD. “Gonadotropins: Luteinizing and Follicle Stimulating Hormones.” VIVO Pathophysiology, Colorado State University, 2018.
    www.vivo.colostate.edu/hbooks/pathphys
    /endocrine/hypopit/lhfsh.html
    .

    How long are blockers used for?

    Hormone blockers are temporary and depending on the prescription, can be taken every 3, 6, or 12 months for as long as 4 years or until the age of 16

    Patient and Family Education | Adolescent Medicine: Puberty Blockers. Seattle Children’s Hospital, 2019, www.seattlechildrens.org/pdf/PE2572.pdf.

    Writer, Clinical Advisor Contributing. “Should There Be a Minimum Age for Gender Transition?” Psychiatry Advisor, 3 Feb. 2020, www.psychiatryadvisor.com/home/topics/gender-dysphoria/medical-guidelines-at-odds-with-public-policy-should-there-be-a-minimum-age-for-gender-transition/2/.

     

    Are blockers harmful to a child's development?

    No, There are no known adverse effects or developmental delays if any child were to go on hormone blockers. 

    However, for any person to go without hormones for several years may have a higher risk of bone density loss and/or Osteoporosis, which is why doctors do not recommend being on blockers over 4 years. 

    This may change over the years once ceasing the use of blockers, reducing the risk back to it’s base level. 

    To help combat this, doctors may recommend taking calcium and Vitamin-D supplements while being on blockers. Some may have their bones checked every 1 or 2 years, depending on the amount of time using blockers.

    Patient and Family Education | Adolescent Medicine: Puberty Blockers. Seattle Children’s Hospital, 2019, www.seattlechildrens.org/pdf/PE2572.pdf.

    Are blockers approved by the FDA?

    Hormone Blockers are approved for treatment of Prostate Cancer, Endometriosis, Fibroids, Central Precocious Puberty however is not yet approved to be used to treat gender dysphoria. However, because they have already been used on children since the 1980’s

    “We can safely and legally recommend puberty blockers for you based on our medical experience and judgement and your specific health needs. The Endocrine Society and the World Professional Association for Transgender Health support puberty blockers. The Food and Drug Administration (FDA) approves puberty blockers for children who start puberty at a very young age, but has not approved puberty blockers for transgender children.” 

    Patient and Family Education | Adolescent Medicine: Puberty Blockers. Seattle Children’s Hospital, Page 3.  2019, www.seattlechildrens.org/pdf/PE2572.pdf.

    “This medication is not specifically made for the purpose of blocking puberty (they are not FDA approved  for this purpose) in transgender youth. However, pediatric endocrinologists (children’s doctors who work with hormones and puberty), recommend these medications if the physical changes of puberty need to be postponed. They have been in use for this purpose for many years.”

    Children’s Hospital of Pittsburg. Patient Information Pubertal Blockers for Patients in Early Puberty . University of Pittsburgh Medical Center, www.chp.edu/-/media/chp/departments-and-services/adolescent-and-young-adult-medicine/documents/gender-and-sexual-development/puberty-blocking-medication-for-early-puberty.pdf?la=en.

    Please keep in mind every child is different and not every child will want or need to use hormone blockers. 

    Why are they used?

    Hormone blockers, such as Lupron, are used to treat many conditions such as:

    • Prostate Cancer
    • Endometriosis
    • Fibroids
    • Central Precocious Puberty (starting puberty before the age of 8-9)
     

    “Lupron Depot (Leuprolide Acetate for Depot Suspension).” Lupron Depot, Jan. 2019, www.lupron.com/.

    As trans children age and puberty is around the corner, they might start experiencing more psychological distress. They may experience higher levels of depression, anxiety, and dysphoria. In severe cases, the child may self harm or express suicidal thoughts or actions over the thought of going through their natal puberty

    Hormone blockers can pause puberty in it’s tracks, preventing further development until the child decides if they want to go through natal puberty or HRT. 

    Hormone Blockers can prevent the psychological distress many trans kids experience during early adolescence.

    Pausing puberty allows them to focus on school, friends, family, sports, clubs, and other activities. As well as improving their general mental health. 

    “Two goals justify intervention with puberty-suppressing hormones:

    (i) their use gives adolescents more time to explore their gender nonconformity and other developmental issues; and

    (ii) their use may facilitate transition by preventing the development of sex  characteristics that are difficult or impossible to reverse if adolescents continue on to pursue sex reassignment.

    Puberty suppression may continue for a few years, at which time a decision is made to either discontinue all hormone therapy or transition to a feminizing/masculinizing hormone regimen.

    Pubertal suppression does not inevitably lead to social transition or to sex reassignment.”

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 18-19. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Do hormone blockers affect fertility?

    No, Hormone blockers alone do not affect one’s ability to reproduce. 
    ________________________________________

    However, the risk of infertility is raised if one was on blockers, then started hormone replacement therapy since the individuals reproductive organs never developed through their natal puberty. 

    Some people can regain their normal fertility rates when ceasing the use of HRT. Everyone’s body is different and if fertility is a concern, speak with a doctor or a fertility specialist.

    Information for Trans and Non-Binary People Seeking Fertility Treatment | Human Fertilization and Embryology Authority, Human Fertilization & Embryology Authority, 2020, www.hfea.gov.uk/treatments/fertility-preservation/information-for-trans-and-non-binary-people-seeking-fertility-treatment/?fbclid=IwAR1TL9VCLcEJsSL6sgWx6a64shX_QgwzRwN4wty30Y8zADLaBn4ZR88JRUQ.

     

    How does a child get on hormone blockers?

    Adolescents may be eligible for puberty-suppressing hormones as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. Some children may arrive at this stage at very young ages (e.g., 9 years of age). Studies evaluating this approach have only included children who were at least 12 years of age. 

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 18-19. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    In order for a child to start hormone blockers

    • “Show a long-lasting and intense pattern of gender nonconformity or gender dysphoria
    • Have gender dysphoria that began or worsened at the start of puberty
    • Address any psychological, medical or social problems that could interfere with treatment
    • Provide informed consent”
    • Is in between Tanner stage 2 -4 of puberty 

    A child must begin puberty FIRST before starting any hormonal transitioning. 

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 13. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    “Pubertal Blockers for Transgender and Gender Diverse Youth.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 16 Aug. 2019, www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075.

    Hormone Replacement Therapy

    What is Hormone Replacement Therapy?

    Hormone Replacement Therapy or HRT, are hormones some trans people may use to reduce dysphoria by gaining the desired sex characteristics.

    This may consist of:
    Testosterones, estrogen, and anti-androgens

    Please keep in mind every child is different and not every child will want or need to use HRT

    What age can a child start HRT?

    HRT can start during adolescence. Commonly around the ages 15 or 16 or with informed consent.

    How does a child start HRT?

    “Initiation of hormone therapy may be undertaken after a psychosocial assessment has been conducted and informed consent has been obtained by a qualified health professional, as outlined in section VII of the SOC. A referral is required from the mental health professional who performed the assessment, unless the assessment was done by a hormone provider who is also qualified in this area.”

    “The criteria for hormone therapy are as follows:

    1. Persistent, well-documented gender dysphoria;
    2. Capacity to make a fully informed decision and to consent for treatment;
    3. Age of majority in a given country (if younger, follow the SOC outlined in section VI);
    4. If significant medical or mental health concerns are present, they must be reasonably well controlled.”

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 34. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    What are the risks of HRT?

    “All medical interventions carry risks. The likelihood of a serious adverse event is dependent on numerous factors: the medication itself, dose, route of administration, and a patient’s clinical characteristics (age, comorbidities, family history, health habits). It is thus impossible to predict whether a given adverse effect will happen in an individual patient. The risks associated with  feminizing/masculinizing hormone therapy for the transsexual, transgender, and gender-nonconforming population as a whole are summarized in Table 2. Based on the level of evidence, risks are categorized as follows: (i) likely increased risk with hormone therapy, (ii) possibly increased risk with hormone therapy, or (iii) inconclusive or no increased risk. Items in the last category include those that may present risk, but for which the evidence is so minimal that no clear conclusion can be reached.” 

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 39. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Likely Increased Risk:

    • Polycythemia
      • Masculinizing hormone therapy involving testosterone or other androgenic steroids increases the risk of polycythemia (hematocrit > 50%), particularly in patients with other risk factors.
      • Transdermal administration and adaptation of dosage may reduce this risk.
    • Weight gain/visceral fat
      • Masculinizing hormone therapy can result in modest weight gain, with an increase in visceral fat.

    Possible Increased Risk:

    • Lipids
      • Testosterone therapy decreases HDL, but variably affects LDL and triglycerides.
      • Supraphysiologic (beyond normal male range) serum levels of testosterone, often found with extended intramuscular dosing, may worsen lipid profi les, whereas transdermal administration appears to be more lipid neutral.
      • Patients with underlying polycystic ovarian syndrome or dyslipidemia may be at increased risk of worsening dyslipidemia with testosterone therapy.
    • Liver
      • Transient elevations in liver enzymes may occur with testosterone therapy.
      • Hepatic dysfunction and malignancies have been noted with oral methyltestosterone. However, methyltestosterone is no longer available in most countries and should no longer be used.
    • Psychiatric
      • Masculinizing therapy involving testosterone or other androgenic steroids may increase the risk of hypomanic, manic, or psychotic symptoms in patients with underlying psychiatric disorders that include
        such symptoms. This adverse event appears to be associated with higher doses or supraphysiologic blood levels of testosterone.

    Inconclusive or No Increased Risk:
    Items in this category include those that may present risk, but for which the evidence is so minimal that no clear conclusion can be reached.

    • Osteoporosis
      • Testosterone therapy maintains or increases bone mineral density among FtM patients prior to oophorectomy, at least in the first three years of treatment.
      • There is an increased risk of bone density loss after oophorectomy, particularly if testosterone therapy is interrupted or insufficient. This includes patients utilizing solely oral testosterone.
    • Cardiovascular
      • Masculinizing hormone therapy at normal physiologic doses does not appear to increase the risk of cardiovascular events among healthy patients.
      • Masculinizing hormone therapy may increase the risk of cardiovascular disease in patients with underlying risks factors.
    • Hypertension
      • Masculinizing hormone therapy at normal physiologic doses may increase blood pressure but does not appear to increase the risk of hypertension.
      • Patients with risk factors for hypertension, such as weight gain, family history, or polycystic ovarian syndrome, may be at increased risk.
    • Type 2 diabetes mellitus
      • Testosterone therapy does not appear to increase the risk of type 2 diabetes among FtM patients overall, unless other risk factors are present.
      • Testosterone therapy may further increase the risk of type 2 diabetes in patients with other risk factors, such as significant weight gain, family history, and polycystic ovarian syndrome. There are no data that suggest or show an increase in risk in those with risk factors for dyslipidemia.
    • Breast cancer
      • Testosterone therapy in FtM patients does not increase the risk of breast cancer.
    • Cervical cancer
      • Testosterone therapy in FtM patients does not increase the risk of cervical cancer, although it may
        increase the risk of minimally abnormal Pap smears due to atrophic changes.
    • Ovarian cancer
      • Analogous to persons born with female genitalia with elevated androgen levels, testosterone
        therapy in FtM patients may increase the risk of ovarian cancer, although evidence is limited.
    • Endometrial (uterine) cancer
      • Testosterone therapy in FtM patients may increase the risk of endometrial cancer, although evidence
        is limited.

    Other Side Effects of Masculinizing Therapy:
    The following effects may be considered minor or even desired, depending on the patient, but are clearly associated with masculinization.
    Fertility and sexual function

    • Testosterone therapy in FtM patients reduces fertility, although the degree and reversibility are
      unknown.
    • Testosterone therapy can induce permanent anatomic changes in the developing embryo or fetus.
    • Testosterone therapy induces clitoral enlargement and increases libido.
      Acne, androgenic alopecia
      Acne and varying degrees of male pattern hair loss (androgenic alopecia) are common side effects of
      masculinizing hormone therapy.

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 101-104. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Likely Increased Risk:

    • Venous thromboembolic disease
      • Estrogen use increases the risk of venous thromboembolic events (VTE), particularly in patients who are over age 40, smokers, highly sedentary, obese, and who have underlying thrombophilic disorders.
      • This risk is increased with the additional use of third generation progestins.
      • This risk is decreased with use of the transdermal (versus oral) route of estradiol administration,
        which is recommended for patients at higher risk of VTE.
    • Cardiovascular, cerebrovascular disease
      • Estrogen use increases the risk of cardiovascular events in patients over age 50 with underlying
        cardiovascular risk factors. Additional progestin use may increase this risk.
    • Lipids
      • Oral estrogen use may markedly increase triglycerides in patients, increasing the risk of pancreatitis and cardiovascular events.
      • Different routes of administration will have different metabolic effects on levels of HDL cholesterol, LDL cholesterol and lipoprotein(a).
      • In general, clinical evidence suggests that MtF patients with pre-existing lipid disorders may benefit from the use of transdermal rather than oral estrogen.
    • Liver/gallbladder
      • Estrogen and cyproterone acetate use may be associated with transient liver enzyme elevations
        and, rarely, clinical hepatotoxicity.
      • Estrogen use increases the risk of cholelithiasis (gall stones) and subsequent cholecystectomy.

    Possible Increased Risk:

    • Type 2 diabetes mellitus
      • Feminizing hormone therapy, particularly estrogen, may increase the risk of type 2 diabetes, particularly among patients with a family history of diabetes or other risk factors for this disease.
    • Hypertension
      • Estrogen use may increase blood pressure, but the effect on incidence of overt hypertension is
        unknown.
      • Spironolactone reduces blood pressure and is recommended for at-risk or hypertensive patients
        desiring feminization.
    • Prolactinoma
      • Estrogen use increases the risk of hyperprolactinemia among MtF patients in the first year of treatment, but this risk is unlikely thereafter.
      • High-dose estrogen use may promote the clinical appearance of preexisting but clinically unapparent prolactinoma.

    Inconclusive or No Increased Risk:
    Items in this category include those that may present risk, but for which the evidence is so minimal that no clear conclusion can be reached.

    • Breast cancer
      • MtF persons who have taken feminizing hormones do experience breast cancer, but it is unknown how their degree of risk compares to that of persons born with female genitalia.
      • Longer duration of feminizing hormone exposure (i.e., number of years taking estrogen preparations), family history of breast cancer, obesity (BMI >35), and the use of progestins likely
        infl uence the level of risk.

    Other Side Effects of Feminizing Therapy:
    The following effects may be considered minor or even desired, depending on the patient, but are clearly associated with feminizing hormone therapy.

    • Fertility and sexual function
      • Feminizing hormone therapy may impair fertility.
      • Feminizing hormone therapy may decrease libido.
      • Feminizing hormone therapy reduces nocturnal erections, with variable impact on sexually
        stimulated erections

     


     

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 98-100. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    How long do they use HRT?

    Trans people who use HRT typically take it for the rest of their lives. They cannot over time start producing their own hormones. 

    Can HRT affect fertility?

    It is common practice for a doctor to talk to their patient about their reproductive health before they start using hormones. 

    Fertility rates depend on the person’s individual risk, how long they’ve been on hormones for, and if they went on hormone blockers first or went through their natal puberty before beginning HRT.  

    Some people can regain their normal fertility rates when ceasing the use of HRT. Everyone’s body is different and if fertility is a concern, speak with a doctor or a fertility specialist.

    It is not impossible for trans people to conceive, carry, and give birth to a healthy child. Many trans adults can and do have their own biological children. 

    Unfortunately, if a child was to use hormone blockers, then use HRT, it is not likely they will be able to have their own biological children.

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 51. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Surgeries

    One of the biggest misconceptions about prepubertal transgender children is claiming parents and doctors are allowing children to undergo genital reconstructive surgeries.

    Young children are having surgeries

    No responsible, licensed,  board certified, physician or surgeon would ever operate on a pre-pubescent child to perform top or bottom surgery. 

    The term “sex change” is an outdated way of describing medically transitioning. Mostly referring to bottom surgery, or surgery on the genitalia.

    What age can transgender children have surgery?

    In the United States of America, 18 is the minimum age requirement to have bottom or top surgery. 

    Unless the individual is over 16 and has Informed Consent.

    Cavanaugh, Timothy, et al. “Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients.” Journal of Ethics | American Medical Association, American Medical Association, 1 Nov. 2016, journalofethics.ama-assn.org/article/informed-consent-medical-care-transgender-and-gender-nonconforming-patients/2016-11.

     

    Informed consent 

    access to any and/or all medical treatments available

    “Genital surgery should not be carried out until

    (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and

    (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity.

    The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.

    Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. 

    The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 21. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Top Surgery

    1. Persistent, well-documented gender dysphoria;
    2. Capacity to make a fully informed decision and to give consent for treatment;
    3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
    4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

    Bottom Surgery
    1.  Persistent, well documented gender dysphoria;
    2. Capacity to make a fully informed decision and to give consent for treatment;
    3. Age of majority in a given country;
    4. If significant medical or mental health concerns are present, they must be well controlled;
    5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless
      hormones are not clinically indicated for the individual);
    6. 12 continuous months of living in a gender role that is congruent with their gender identity.

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 105-106. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Frequently Asked Questions

    Why can't they just wait until they turn 18?

    “Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents. “

    Going on hormone blockers first may prevent certain surgeries or procedures needing to be done in the future.

    For example a trans man who went on blockers, then testosterone would no not need to undergo top surgery when they’re older.

    Or a trans woman who went on blockers, then HRT would not need to undergo facial feminization surgery.

    Coleman, Eli, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Page 21. The World Professional Association for Transgender Health, 2012, www.wpath.org/media/cms/Documents/SOC v7/Standards of Care_V7 Full Book_English.pdf.

    Can children grow out of Gender Dysphoria?

    Do some children no longer suffer from Gender Dysphoria when they hit puberty?  Yes

    Do some children’s dysphoria/identity get worse/stronger when they hit puberty?
    Yes

    The main signs to look out for is insistence, persistence, and consistence.
     
    • Insistent that one is the other gender
    • Persistent that you call them by a new name and pronouns
    • Consistently is identifying as that gender
    BBC film on child transgender issues worries activists | Society | The GuardianMany anti-LGBTQ organizations such as American College of Pediatrics will all site the same person, Dr. Kenneth Zucker , Ph.D., C.Psych.
     
    In May of 2008, he was named the chair of the American Psychiatric Association work-group on “Sexual and Gender Identity Disorders” for the 2012 edition of the DSM-5. The APA stated:
     
    “Dr. Zucker has published 97 peer-reviewed journal articles, 48 book chapters, and a landmark textbook…. Dr. Zucker and his team have evaluated over 900 children and youth with gender identity issues. Dr. Zucker is one of the few researchers who is doing long-term follow-up of the patients he has treated.”


    However, many pro-LGBTQ activists claim his methods are conversion therapy as he attempts to make children comfortable in their sex assigned at birth.

    He has said most children who had Gender Dysphoria, will no longer experience gender dysphoria when they hit puberty. Zucker tries to encourage children to accept the sex they were assigned at birth but also helps them transition if they continue to feel dysphoria when they hit puberty. He recommends parents setting strict limits and not allow them to socially transition

    Goleman, Daniel. “The ‘Wrong’ Sex: A New Definition Of Childhood Pain.” The New York Times, The New York Times, 22 Mar. 1994, www.nytimes.com/1994/03/22/science/the-wrong-sex-a-new-definition-of-childhood-pain.html.

    McQuigge, Alanna Rizza and Michelle. “Former CAMH Psychologist Defends His Work at Youth Gender Identity Clinic.” CityNews Toronto, 10 Oct. 2018, toronto.citynews.ca/2018/10/09/former-camh-psychologist-defends-his-work-at-youth-gender-identity-clinic/.

    American Academy of Pediatrics: “The GACM is best facilitated through the integration of medical, mental health, and social services, including specific resources and supports for parents and families. Providers work together to destigmatize gender variance, promote the child’s self-worth, facilitate access to care, educate families, and advocate for safer community spaces where children are free to develop and explore their gender. A specialized gender-affirmative therapist, when available, may be an asset in helping children and their families build skills for dealing with gender-based stigma, address symptoms of anxiety or depression, and reinforce the child’s overall resiliency. There is a limited but growing body of evidence that suggests that using an integrated affirmative model results in young people having fewer mental health concerns whether they ultimately identify as transgender.”

    Rafferty, Jason, et al. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Oct. 2018, pediatrics.aappublications.org/content/142/4/e20182162?fbclid=IwAR2dgqrQdKWWjtPcR299PFWJotL6FyBVXUpJp5Knl8gLMvP-QO9GvoDndqs.

    The American Psychiatric Association:A child’s treatment typically involves a multi-disciplinary team of health care professionals, which may include a pediatrician, a psychiatrist, other mental health professionals, a pediatric endocrinologist (specialists in hormone conditions in children) and an advocate. Treatment may focus primarily on affirming psychological support, understanding feelings and coping with distress, and giving children a safe space to articulate their feelings. For many children the feelings do not continue into adolescence and adulthood.”

    Parekh, Ranna. What Is Gender Dysphoria?, Treatment, American Psychiatric Association, Feb. 2016, www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

    My kid showed no signs, are they still trans?

    “While some children express feelings and behaviors relating to gender dysphoria at 4 years old or younger, many may not express feelings and behaviors until puberty or much later. For some children, when they experience puberty, they suddenly find themselves unable to identify with their own body. Some adolescents become unable to shower or wear a bathing suit and/or undertake self-harm behaviors.”

    Parekh, Ranna. What Is Gender Dysphoria?, American Psychiatric Association, Feb. 2016, www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

    What is Rapid Onset Gender Dysphoria?

    New paper ignites storm over whether teens experience 'rapid onset' of transgender identity | Science | AAASRapid Onset Gender Dysphoria  (ROGD) is a theory created by Dr. Lisa Littman of Brown University, that a child or teenager can be influenced by other transgender peers and social media, into “suddenly” experiencing gender dysphoria and coming out as trans.  Suggesting it is a “social coping mechanism” for other mental disorders like depression and anxiety caused by trauma during adolescence. 

    She coined this term after conducting a survey of 256 parents where 80% suddenly noticed their child experiencing gender dysphoria and coming out as transgender or non-binary without any prior signs throughout their life. 

    “Lisa Littman Assistant Professor of the Practice of Behavioral and Social Sciences.” Littman, Lisa, Brown University, 2018, vivo.brown.edu/display/llittman.

    Littman, Lisa. “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria.” PloS One, Public Library of Science, 16 Aug. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6095578/.

     

     

     

    After the study was released, it went viral, gaining controversy for causing harm to the community due to people citing the survey mistaking it as a credible ignoring the numerous errors in the methodology. 

    1. Low Sample size.
    2. Survey is about transgender children yet interviews parents who suspect their child might be trans.
    3. Participants were recruited from transantagonistic websites.
    4. Does not take into account the possibility of children feeling more comfortable being themselves when they meet others who feel the same way.
    5. Parents assume the child showed no signs, ignoring the possibility of parents missing or ignoring signs the child gave.
    6. Did not define ROGD to the participants 
    7. Asked parents to self “diagnoses” their child using DSM-5 criteria for gender dysphoria in (1) childhood and (2) in adolescence and adulthood (i.e., current age
    8. and more…

    “Littman’s methodological flaws in the conceptualization and design of the study illustrate the importance of and need for more rigorous survey design and data analysis in descriptive studies. In the context of research with transgender people, who have historically been subjected to pathologizing research, flawed methodologies that lead to tenuous conclusions can have serious implications.” 

    Restar, Arjee Javellana. “Methodological Critique of Littman’s (2018) Parental-Respondents Accounts of ‘Rapid-Onset Gender Dysphoria.’” Archives of Sexual Behavior, Springer US, 22 Apr. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC7012957/.

    B.C.L., LL.B. Ashley, Florence. “There Is No Evidence That Rapid-Onset Gender Dysphoria Exists.” Psych Central, 3 Dec. 2018, psychcentral.com/lib/there-is-no-evidence-that-rapid-onset-gender-dysphoria-exists/.

     
     

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