Clinicians treating children with gender dysphoria, the children themselves, and their parents, are faced with a dilemma – early use of puberty suppressing drugs (followed later by further hormonal treatments) will likely make it easier for the young person to gender transition in due course, and the earlier that process begins, the more effective it is likely to be. However, intervening earlier comes with the possibility that the child’s feelings of gender dysphoria would have dissipated naturally, or that they may later de-transition (that is, change their mind about wanting to transition to the other gender), leaving them with potentially irreversible bodily changes caused by the hormonal treatment.
According to a systematic review published recently in the journal Pediatrics, adding to this clinical dilemma is a dearth of quality data on the physical and psychosocial effects of hormonal treatments on gender dysphoric children, teenagers and young adults. The limited evidence that is available provides “qualified support” for these treatments, the review concludes.
The new findings – based on an exhaustive search of any and all relevant studies published between 1946 and 2017 – are published at a time when the medical and allied professions have shifted toward an increasingly “affirmative” approach toward gender dysphoria, one that at the extreme involves encouraging the process of transition at the very first signs of the condition.
The British Psychological Society’s own guidelines from 2012 propose offering “a series of [five] staged treatments”, to give time for the young person to consider their options, beginning with psychological exploration and escalating, if the dysphoria persists, to the use of puberty suppressing hormones and culminating in surgery.
The guidelines of the Endocrine Society (an International body based in Washington DC) are more affirmative: “We suggest that clinicians begin pubertal hormone suppression after girls and boys [diagnosed with gender dysphoria] first exhibit physical changes of puberty”.
However, the new review reveals how this advice is based on extremely limited evidence. When it comes to children, teens and young adults aged under 25, we simply do not yet know much about the psychosocial effects of pubertal suppressors (including gonadotropin-releasing analogs which suppress the development of secondary sexual characteristics) and further hormonal treatments (both gender-affirming hormones and cross-hormonal treatments, such as anti-androgens, which counter the effects of testosterone, and progestins, which suppress the menses).
Denise Chew at the University of Melbourne and her colleagues identified only thirteen relevant studies, and – by necessity in many cases given the context – most of these involved small samples, only two featured a control group, and none involved blinding or randomisation (the gold standard approach for medical trials).
The limited evidence available suggests that these interventions are “relatively safe” in terms of their physical side-effects, although there is no long-term data (including potential adverse effects on fertility). Where short-term side-effects occur, these can include, among others, hot flushes, fatigue, weight gain and, most concerning, changes to bone mass density.
Puberty suppressors appear to be effective at having their intended physical effect – that is, preventing pubertal changes associated with the person’s sex assigned at birth. They also have welcome emotional and behavioural benefits, such as reducing depression. However, on their own they do not appear to alleviate gender dysphoria (in fact one study found a trend in the opposite direction, and increased negative body image). The researchers said this is “probably not surprising” given that puberty suppressing drugs “cannot be expected to lessen the dislike of existing physical sex characteristics associated with an individual’s birth-assigned sex nor satisfy their desire for the physical sex characteristics of their preferred gender”.
Meanwhile, the next stage of gender affirming treatments and cross-hormonal treatments are successful, to a degree, in achieving the intended physical changes in line with the desired gender, current evidence suggests. However, these often do not match the hopes of the person with gender dysphoria – for instance, one study found oestrogen led to a degree of breast growth that most of those treated found unsatisfactory. There are some cognitive effects to consider – for instance, after taking puberty suppressing drugs, teenagers born male but seeking to transition to female, subsequently showed poorer performance on tests of executive functioning and mental rotation. Perhaps most concerning – especially given the psychological vulnerability of many teens with gender dysphoria – there is simply no data on the psychosocial effects of these treatments.
This lack of data is in the context of a growing concern among some psychologists and psychiatrists that the affirmative approach may have gone too far. For example, psychologist Dianne Berg, Co-Director of the National Center for Gender Spectrum Health in the US (which advocates an affirmative approach), told The Atlantic recently “Under the motivation to be supportive and to be affirming and to be nonstigmatizing, I think the pendulum has swung so far that now we’re maybe not looking as critically at the issues as we should be.”
One critical issue that has yet to be addressed by research at all, is what the effects are of hormonal treatments on children and teens who later de-transition. As of now, Chew and her team say there are “no known studies to date in which researchers have reported the rates and circumstances under which transgender youth cease their hormonal therapy in an unplanned manner or the risk of subsequent regret.” While the researchers say their review provides “qualified support” for the use of puberty suppressors and hormonal treatments, they conclude that more better quality and long-term research is essential, including data on the psychological effects of these interventions.
NB. On July 31, 2018 the headline to this post was changed, together with a few other minor amendments, following feedback from one of the review authors.
—Gender dysphoria [Information from NHS Choices]
—When Children Say They’re Trans [recent in-depth article in The Atlantic]
—Childline [support and guidance for children and young people aged under 19]
—Samaritans [support and guidance for anyone]