Puberty blockers, cross-sex hormones and surgery for transgender minors? UPDATE-New WPATH Standards of Care

[tall73]

Should it be legal to use hormone blockers, cross-sex hormones, and surgery in treating transgender minors? Concerns have been raised about whether minors can comprehend the ramifications and consent to such procedures.

Can children as young as 8 make an informed decision about puberty blockers, or as young as 11 make decisions about cross-sex hormones?

Would a 13 year old understand all that is involved in top surgery to remove breasts?

Is it possible for a 15 year old to think through all the long-term effects of removing a penis and the creation of a neo-vagina from the materials?

Can a 16 year old comprehend all the results of a hysterectomy?

(See posts after this for evidencde of the above practices).

Here is a video testimony of a 17 year old who was transitioned from age 13-16 who is now de-transitioning. She indicates she could not understand the ramifications of the medical decisions she made. Her breasts were removed, she has blood clots in urine, cannot fully empty her bladder,and the doctors are not sure if she can carry a child to term.

----------------
Edited October 7 to add:

When this thread was initiated the process was underway to revise the WPATH (World Professional Association for Transgender Health) Standards of Care.

Version 8 has now been released. The standards of care are considerably longer, and contain significant changes. One specific change as it relates to this thread is in regards to surgical interventions for minors. I have underlined key areas for comparison.

Standards of Care: Version 7

​

Irreversible Interventions​

Genital surgery should not be carried out until (i) patients reach the legal age of majority 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.​

Standards of Care Version 8

INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH S133​

6.10- We recommend health care professionals working with transgender and gender diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development.​

6.11- We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible. ​

​

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them​

must be met):​

6.12- We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:​

6.12.a- the adolescent meets the diagnostic criteria of gender incongruence as per the ICd-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICd, other taxonomies may be used although efforts should be undertaken to utilize the latest ICd as soon as practicable.​

6.12.b- the experience of gender diversity/incongruence is marked and sustained over time.​

6.12.c- the adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.​

6.12.d- the adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.​

6.12.e- the adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.​

6.12.f- the adolescent has reached tanner stage 2 of puberty for pubertal suppression to be initiated.​

6.12.g- the adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.​

 

[tall73]

Puberty blockers as young as 8

Impact of Early Medical Treatment for Transgender Youth: Protocol for the Longitudinal, Observational Trans Youth Care Study

To be considered eligible for enrollment in the blocker cohort, youth must have met the following criteria: presence of gender dysphoria as determined by a clinician; Tanner stage 2, 3, or 4 of sexual development; appropriateness to undergo puberty suppression with GnRHa; age of 8-16 years; ability to read and understand English; and receiving or planning to receive clinical services at a study site clinic.​

​

Initial data from youth enrolled in the blocker cohort across all study sites (n=90) demonstrate that the age of participants ranges from 8 to 16 years at enrollment, with a mean age of 11 (SD 1.5) years.​

Cross sex hormones offered to 8 year olds, actually tested on 11 year olds

To be considered eligible for enrollment in the gender-affirming hormone cohort, participants must have met all the following criteria: presence of gender dysphoria as determined by a clinician, appropriateness for initiating phenotypic gender transition with gender-affirming hormones by the team, age of 8-20 years, ability to read and understand English, and receiving or planning to receive services at a study site clinic. T​

​

Regarding age, the minimum age in the inclusion criteria for the gender-affirming hormone cohort was decreased from 13 years (as stated in the original grant proposal) to 8 years in order to ensure that potential participants who might be eligible for hormones based on their Tanner stage would not be excluded due to age alone. Additionally, considerations were made for youth who were found to have very low bone density in the screening, which occurs with youths initiating blockers.​

​

Participants in the gender-affirming hormone cohort range in age from 11 to 20 years at enrollment, with a mean age of 16 (SD 1.9) years.​

Physiologic Response to Gender-Affirming Hormones Among Transgender Youth - PubMed

Purpose: The purpose of this study was to examine the physiologic impact of hormones on youth with gender dysphoria. These data represent follow-up data in youth ages 12-23 years over a two-year time period of hormone administration.​

​

Methods: This prospective, longitudinal study initially enrolled 101 youth with gender dysphoria at baseline from those presenting consecutively for care between February 2011 and June 2013. Physiologic data at baseline and follow-up were abstracted from medical charts. Data were analyzed by descriptive statistics.​

​

Results: Of the initial 101 participants, 59 youth had follow-up physiologic data collected between 21 and 31 months after initiation of hormones available for analysis. Metabolic parameters changes were not clinically significant, with the exception of sex steroid levels, intended to be the target of intervention.​

​

Conclusions: Although the impact of hormones on some historically concerning physiologic parameters, including lipids, potassium, hemoglobin, and prolactin, were statistically significant, clinical significance was not observed. Hormone levels physiologically concordant with gender of identity were achieved with feminizing and masculinizing medication regimens. Extensive and frequent laboratory examination in transgender adolescents may be unnecessary. The use of hormones in transgender youth appears to be safe over a treatment course of approximately two years.​

 

[tall73]

Surgeries are also being performed on minors.

Vaginoplasty at age 15:

https://www.transgendercounseling.com/temp/wp-content/uploads/2018/09/Milrod-Karasic-2017-FINAL.pdf

Nine surgeons had never performed vaginoplasty on a transgender female minor, and the remaining 11 participants reported 1 to 20 cases per surgeon. Of the 11 surgeons who had performed vaginoplasty on a transgender female minor, 10 were in private practice. Reported ages of minors undergoing surgery ranged from 15 to “a day before 18” years (surgeon 7). Most participants had noticed a definite increase in the number of minors requesting information about the procedure on their own or being referred for vaginoplasty by their mental health providers.​

Chest surgery at age 13

Chest Dysphoria and Chest Reconstruction Surgery in Transmasculine Youth

The mean (SD) age at chest surgery in this cohort was 17.5 (2.4) years (range, 13-24 years), with 33 (49%) being younger than 18 years. Of the 33 postsurgical participants younger than 18 years at surgery, 16 (48%) were 15 years or younger.​

Hysterectomy at 16:

Hysterectomy as Gender-Affirmation Surgery in... : Obstetrics & Gynecology

​

METHODS:​

Retrospective chart review of 15 trans men (female-to-male transgender persons), age 16-43, who underwent hysterectomy by a single surgeon at our academically-affiliated community hospital from 2012-2016. Three patients participated in a focus group aimed at optimizing perioperative care.​

Free To Be He, She, They

UCSF’s pioneering Child and Adolescent Gender Center is helping a growing number of families seeking advice – and increasingly, medical intervention – to help a son or daughter’s physiology match their gender identity.​

​

By age 15, Oliver Bishop was on a dual regimen of testosterone, plus puberty blockers to keep his endogenous estrogen from competing with the male hormones.​

​

He came out to his classmates by creating a second Facebook account with his new name, chosen after he asked his mom what it would have been if he had been born male: Oliver, after his great-grandfather.​

​

While he had to endure a second puberty, and he’ll need to take testosterone for the rest of his life, he’s had no second thoughts about transitioning.​

​

The summer after his sophomore year, he had “top” surgery – a double mastectomy and male chest contouring – in San Francisco. To pay for the procedure, which was not covered by insurance, he used earnings from years of showing and selling pigs at the Tuolumne County fair.​

​

“It’s a lot of money for a 15-year-old,” he says of the $8,000 price tag. “But I appreciate it every day.”​

​

His family’s insurance also wouldn’t cover a puberty blocker implant, so Bishop at first chose cheaper but “gnarly” monthly shots. Later, concerned about unknown long-term effects of the blockers, and hating the painful shots, he opted for a hysterectomy at age 16 – performed by the same family doctor who had delivered him.​

Edited to add in Oct . 2023:

This data is now a couple years old, with trends at the time growing rapidly. It gives some ideas of numbers of youth receiving interventions in recent years.

Number of transgender children seeking treatment surges in U.S.

About 42,000 U.S. children ages 6 to 17 were diagnosed with gender dysphoria in 2021, nearly triple the number in 2017, a unique data analysis for Reuters found.

www.reuters.com

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth. Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021.​

​

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis. This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.​

​

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.​

​

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.​

​

​

​

 

[tall73]

EDITED Oct. 10, 2023 to note: The quotes from the WPATH standards are form version 7. Version 8 was in development when this thread started, but are now published. See later in the thread for discussion on version 8.


Those minors who receive such interventions usually are being treated for gender dysphoria.

The WPATH (World Professional Association of Transgender Health) Standards of Care indicate the following about gender dysphoria:

https://www.wpath.org/media/cms/Documents/SOC v7/SOC V7_English2012.pdf?_t=1613669341

​

Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Institute of Medicine, "2011). Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974. Knudson, De Cuypere, & Bockting, 2010b). Only some gender-nonconforming people experience gender dysphoria at some point in their lives.​

​

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood. Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6-23"'% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995*). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12-27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, "2008).​

The WPATH guidelines have held that surgery should not be undertaken until the age of majority.

https://www.wpath.org/media/cms/Documents/SOC v7/SOC V7_English2012.pdf?_t=1613669341

Irreversible Interventions​

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.​

Despite this surgeries are being performed on minors. And a proposed revision to the WPATH guidelines are in progress.

The Battle Over Gender Therapy

When WPATH released the draft of the SOC8 for public comment, Leibowitz and his co-authors braced for the inevitable conservative attack. For teenagers who have parental consent, the draft adolescent chapter lowered to 14 (from 16 in the previous guidelines) the recommended minimum age for hormone treatments, which can permanently alter, in a matter of months, voice depth and facial and body hair growth and, later, other features like breast development. It set a minimum recommended age of 15, for breast removal or augmentation, also called top surgery. (The previous standards didn’t set a minimum age.)​

​

The 62-page final version of the adolescent chapter, which WPATH sent me the first week of June, is scheduled to be released this summer. It will include a key change in the top-line recommendations of the SOC8, in response to advocates like International Transgender Health. In place of the December draft’s recommendation of evidence of several years of gender incongruence before a preteen or teenager begins any medical intervention, the final chapter set a vaguer timeline: gender incongruence that is “marked and sustained over time.” Below their recommendations, Leibowitz, de Vries and their committee did note that several years of experience is important for teenagers who want hormones and surgery but said that for puberty suppressants, several years was “not always practical or necessary.” In the end, the chapter sided with the trans advocates who didn’t want kids to have to wait through potentially painful years of physical development.​

​

Leibowitz, de Vries and their co-authors held their ground on assessments. The final version of their chapter said that because of the limited long-term research, treatment without a comprehensive diagnostic assessment “has no empirical support and therefore carries the risk that the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.”​

​

“Sometimes I feel that the field is so polarized that I worry whether the guidelines will be followed — how much authority will they have?” de Vries said of the upcoming publication of the chapter. “But I think a sensible reader will read a very nuanced, thoughtful approach that will help those who really need it.”​

One of the reasons that treatment is often recommended is due to the risk of suicide among those suffering from gender dysphoria:

The Battle Over Gender Therapy

The rate of suicide attempts among them in the previous year is terribly high — nearly 35 percent in a 2017 survey of high school students by the Centers for Disease Control and Prevention compared with single digits for the cisgender population.​

 

[tall73]

In 2015 the National Institutes of Health funded a multi-year study evaluating outcomes of medical treatment of youths:

NIH funds first multi-site study of transgender youth in the US with a $5.7 million award

The National Institutes of Health has awarded $5.7M for a five-year, multicenter study which will be the first in the U.S. to evaluate the long-term outcomes of medical treatment for transgender youth. This study will provide essential, evidence-based information on the physiological and psychosocial impact, as well as safety, of hormone blockers and cross-sex hormone use in this population.​

​

The multicenter study will be located at four academic medical centers with dedicated transgender youth clinics. The co-investigators and their institutions include:​

​

-Johanna Olson, MD, Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California​

-Stephen Rosenthal, MD, UCSF Benioff Children's Hospital San Francisco​

-Robert Garofalo, MD, MPH, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine​

-Norman Spack, MD, Boston Children's Hospital and Harvard Medical School​

 

[tall73]

More information on hormone blockers and cross-sex hormones.

The Battle Over Gender Therapy

For them, families weigh the relief the medications can provide against the health implications. Taking puberty suppressants (or hormones) for gender affirmation is “off-label,” meaning this specific use of the medications is not approved by the Food and Drug Administration. Off-label prescriptions are common and don’t imply anything improper, but there may be less research about the drug’s effects. If young people continue on to hormone treatments, puberty suppressants “probably” compromise fertility, especially for trans girls, Stephen M. Rosenthal, a pediatric endocrinologist at the gender center at U.C.S.F. who is on the group for the SOC8 chapter on hormone treatments, explained in a review last year for Nature Reviews Endocrinology. The medication can also prevent bone density from increasing as it typically would, and while levels returned to normal in trans boys who went on to hormone therapy, they remained low in trans girls who did the same, according to a 2020 study from the Amsterdam clinic. Little is known about the impact on brain development. “The relative paucity of outcomes data raises notable concerns,” Rosenthal wrote in his review.​

Olson-Kennedy, conference, Gender Odyssey 8/25/17

We have to think about these things. Blocking is one tool that’s an awesome tool for a lot of people. And what does that mean? Does that mean that trans feminine, trans girls who get blocked in tanner 2, we are making the assumption that all of them are going to have genital surgery? Are we doing that? Because we might be doing that. I’m just saying we might be doing that. And so that actually is worthy of a conversation. Because many trans women do not have genital surgery. Love their genitals, enjoy their genitals, like to use them. That’s fantastic. We love people who love their bodies and use them and enjoy them. That’s a great human place to be. But we have to ask ourselves if you have tanner 2 male genitals are you going to be able to use them, are you going to want to be able to use them? Or we are we, just assuming that everybody is now going to have to say ‘Well I either need to go through puberty to get adult sized genitals or I’m going to have these genitals that I have or I’m getting surgery.’​

Those who are blocked do not develop their sexual organs to maturity. This can result in less or no sexual function after transition.

The Battle Over Gender Therapy

​

Shrier also quoted Marci Bowers, a gynecologic and reconstructive surgeon who is slated to be the next president of WPATH, who voiced a separate concern about blocking puberty too early. Though there is no published data on this question, over hundreds of surgeries, Bowers has found that trans girls who don’t go through male puberty may find it difficult to have an [bless and do not curse][bless and do not curse][bless and do not curse][bless and do not curse][bless and do not curse][bless and do not curse] after they have genital surgery as adults. They also could have less penile tissue with which to create a vagina, which can lead to more complications from surgery, according to Bowers.​

If they decide not to go through with surgery they have to go off of hormone blockers, even though they have already taken on any health impacts, and then go through delayed puberty.

If someone is on hormone blockers, then goes onto cross sex hormones it can result in sterilization. This is important because some who transition later in life can go off hormone treatment and still have children.

Q&A with Norman Spack - The Boston Globe

SPACK: The biggest challenge is the issue of fertility. When young people halt their puberty before their bodies have developed, and then take cross-hormones for a few years, they'll probably be infertile. You have to explain to the patients that if they go ahead, they may not be able to have children. When you're talking to a 12-year-old, that's a heavy-duty conversation. Does a kid that age really think about fertility?​

 

[Fantine]

I would imagine health insurance companies would require massive amounts of documentation before approving such surgery on minors, and let's face it, it would be cost prohibitive otherwise.
They would probably require less documentation for pharmaceutical intervention which would most likely be reversible, since puberty would occur after cessation.
I think the insurance companies would be excellent gatekeepers against abuse.
Of course there is medical tourism.

 

[Yttrium]

The whole point to puberty blockers is to delay the decision until the child matures enough to make the decision. I don't have a problem with them.

I think anything else should wait until adulthood.

 

[tall73]

I would imagine health insurance companies would require massive amounts of documentation before approving such surgery on minors, and let's face it, it would be cost prohibitive otherwise.
They would probably require less documentation for pharmaceutical intervention which would most likely be reversible, since puberty would occur after cessation.
I think the insurance companies would be excellent gatekeepers against abuse.
Of course there is medical tourism.

Some information regarding insurance:

The Battle Over Gender Therapy

​

Most of the young people today who come to clinics for treatment are affluent and white, live in progressive metropolitan areas and have health insurance. For them, gender-related care has become more accessible since 2016, when the Obama administration included gender identity in a rule against denying health care benefits on the basis of sex. If a provider deems the care medically necessary, it’s possible to get insurance coverage for puberty suppressants, which can be injected or implanted under the skin, and hormone treatments, which can be taken orally, injected or applied as a gel or a patch. Each can cost thousands of dollars a year.​

Surgical procedures are often not covered. I posted the example in one of the posts about the young individual who had to work to pay off top surgery and a hysterectomy.

 

[wendykvw]

The side effects of the drugs are horrendous. 15 year old girls getting osteoporosis is not helpful. Many more. It is not good to mess with mother nature.Mental health concerns should be addressed not by a pill but through psychiatric help.

 

[archer75]

The poor young woman in this video is a victim of a cult run by pedophiles.

They need to generate "trans" youth (sacrifices) in order to justify the plans to get pedophiles into secret "classes" with kids that parents aren't allowed to know about. To exploit and trick and use the most vulnerable of all ages.

 

[archer75]

The whole point to puberty blockers is to delay the decision until the child matures enough to make the decision. I don't have a problem with them.

I think anything else should wait until adulthood.

1) Puberty is not a decision.
2) That is not the point. The point is to get them on a track that is very hard to get off.

 

[Chesterton]

When the Nazis and Japan's Unit 731 did this kind of stuff, it came to be known as war crimes. I hope these will someday be seen as our culture war crimes.

 

[archer75]

When the Nazis and Japan's Unit 731 did this kind of stuff, it came to be known as war crimes. I hope these will someday be seen as our culture war crimes.

I don't see that they're being committed as part of or under cover of a war, but I do hope they are soon seen as similar atrocities.

 

[tall73]

There are concerns, even among those performing such surgeries, that young people could be influenced by culture, social media, peers, etc.

https://www.transgendercounseling.com/temp/wp-content/uploads/2018/09/Milrod-Karasic-2017-FINAL.pdf

In addition, a few participants urged caution, suggesting that some adolescents engage in gender exploration as part of a developmental phase and as part of the current zeitgeist:​

​

Depending on how old they are, there are a lot of classes that adolescents, even pre adolescents in elementary schools, are getting these days. And they are trying to figure out if they are doing it because it is a new norm, versus what they really want. I have seen some of my patients’ children go through phases of in and out, of thinking transgender. So that would be my concern—is it because it is popular now?​

Discussing the revision of WPATH guidelines:

The Battle Over Gender Therapy

As they wrote in their December draft chapter, part of the rise in trans identification among teenagers could be a result of what they called “social influence,” absorbed online or peer to peer. The draft mentioned the very small group of people who detransition (stop identifying as transgender), saying that some of them “have described how social influence was relevant in their experience of their gender during adolescence.” In adolescence, peers and culture often affect how kids see themselves and who they want to be. Their sense of self can consolidate, or they can try on a way of being that doesn’t prove right in the long run as the brain further develops the capacity for thinking long-term.​

 

[Fantine]

I know one trans woman who went back to being male because she wound up in the hospital and was told the transition was putting her life in danger.

I am sure he is struggling, but he is aluve.

 

[SavedByGrace3]

In Muslim countries, they perform female genital mutilation, and people are outraged.
Ironic.

 

[Belk]

The minute people talk about outlawing irreversible body altering religious ceremonies I'll start taking the current moral panic about trans people seriously.

 

[Desk trauma]

The minute people talk about outlawing irreversible body altering religious ceremonies I'll start taking the current moral panic about trans people seriously.

Let’s start with disallowed Metzitzah B’peh as opposed to explicitly protecting it even when moyles are transmitting herpes doing it.

 

[Pommer]

In Muslim countries, they perform female genital mutilation, and people are outraged.
Ironic.

Do they now?
Which countries would these be?
I hear tell that the practice is in the middle-east and in several African nations of both Muslim and Christian persuasions.