A topic that comes up often in my work is the question of whether or not to treat transgender youth with cross-sex hormones. (For those of you who don’t know, this would include a Male to Female preteen/teen taking Estrogen, and a Female to Male preteen/teen taking Testosterone, in order for them to go through puberty in line with their brain gender identity. Read more about it here). I know this is a controversial topic, and there are as many opinions about this as there are professionals, if not people.
Of course, the first step in treating a transgender child about to enter puberty is usually hormone blockers. While incredibly expensive, I think most parents and doctors are more willing to allow the child/pre-teen to go on these because a) it buys them time, b) it prevents physical changes from happening during puberty that have to be “undone” later, and c) the changes are reversible. Remove the hormone blocker, and the individual goes through the puberty of their natal sex. Not so with cross-sex hormones. Many changes are irreversible, and can have life-long impact on one’s reproductive system. I understand the anxiety parents and doctors feel about transgender pre-teens starting hormones. I’m still a proponent of it, on a case by case basis.
I recently learned that the Endocrine Society guidelines recommend that endocrinologists wait to put pre-teens/teens on cross-sex hormones until the age of 16. In my opinion, this is too late. Most of their peers will be going through or will have gone through puberty by that age. One argument I’ve heard about this is that there are “late bloomers”. Sure, there are “late bloomers”, but these teens need not be. Being late to enter puberty means something entirely different to a non-transgender teen and a transgender teen. The former may be anxiously awaiting puberty. The latter may be close to suicide.
For those youth who do receive hormone blockers, this is a life-changer: their body is not going to go through the “wrong” puberty. However, even these pre-teens and teens struggle with gaining those important “gender markers” in order to help them pass in society; a deeper voice and facial hair for male teenagers, a more curvaceous figure for female teenagers. Without the needed physical help from hormones, passing can be very difficult. And being read as the wrong gender every day is an agony no teen should have to go through.
In my opinion, treatment before the age of 16 is medically necessary to support the mental health of transgender youth. I suppose if more people sat across from transgender pre-teens and teenagers the way I do, more people would agree. I see a sadness and a desperation in their eyes I simply do not think has to be a part of this process. I don’t have all the answers; I don’t have a medical degree that would help me understand exactly the process of cross-sex hormones in an adolescent’s body. I’m coming from a therapist’s standpoint who understands how crucial it is for teens to feel as though they fit in with their peers -as well as the need to be seen for who they really are- and the depression and suicidality that results when they don’t.
In the words of Karen, the mother of an FTM individual and author of the blog Trans*forming Family, “When a child is as sure as my son is, I think it is senseless and really torturous to make them wait until they reach some arbitrary age guideline. I realize this is anecdotal, but every trans teen I’ve known of who has been suicidal, depressed, or has self-harmed has been in that age range where they cannot get cross-gender hormones and/or surgery and are miserable due to dysphoria[…] the negative symptoms lift after medical transition, so why prolong their suffering unnecessarily?”.
Monica Nuñez-Cham leads the family support group for families with gender nonconforming and transgender children in San Diego. She is also the mother of Isaac (now 18), an FTM individual who started medical transition (cross-sex hormones soon followed by surgery) at the age of 13. “He wanted so badly to appear male and experience the same changes his friends were having (lower voice, facial hair, etc). He was very uncomfortable in his body and hated every feminine form (hips, butt, chest). I knew that the physical changes of T would help others who knew him as a “girl” to perceive him as male. The risks (that nobody could explain with certainty to me because there is not much research) were much lower than the 100% reality of seeing my dearest child in emotional pain every day and withdrawing himself from life. […] I always tried to listen to my heart and do what I thought was the best for him, with the tools I had at the time.
Hormones and surgery were the best decision we could have made. Isaac as a little boy was a happy one, always singing, talking, making friends and very easily expressed his feelings by kissing, hugging and verbally. Close to puberty he stopped being happy, to the point of not allowing me to touch him. After the T, he came back, not little by little, suddenly he was the same happy kid. After the surgery I was very surprised to see him just BLOSSOM in a spectacular manner.
I attribute his success as a person (academically, socially, emotionally) to the fact that we acted as soon as we knew how.”
The Harry Benjamin (now WPATH) Standards of Care were revised 7 times. In my opinion, the first version was hopelessly damaging to transgender individuals seeking treatment. By the 7th version, it is finally coming around to the way it should be: professionals supporting and making life easier for transgender individuals, not harder. Additionally, the Standards of Care were only created to be general guidelines to give those who are inexperienced some semblance of a plan. They are not laws that govern how a professional chooses to treat a transgender individual. Such is the same as the guidelines for the Endocrine Society, in fact it says so in their disclaimer statement: “Clinical Practice Guidelines are developed to be of assistance to endocrinologists by providing guidance and recommendations for particular areas of practice. The Guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The Guidelines cannot guarantee any specific outcome, nor do they establish a standard of care. The Guidelines are not intended to dictate the treatment of a particular patient. Treatment decisions must be made based on the independent judgment of health care providers and each patient’s individual circumstances.”
Wondering what the latest version of the Standards of Care say (in part) regarding prescribing hormones to transgender adolescents? “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.”
I know of two gender clinics in all of Southern California who medically treat transgender youth.* These clinics, as you can imagine, have long waiting times due to the high demand and sheer number of patients in need.
I’ve said it before, and I’ll say it again. I see my role as helping individuals live their lives as the gender they are in their brains. Most of the time this is not about helping them figure out their gender identity, but figuring out what they are going to do about it. For those children/pre-teens/teens who know who they are, and what they want to do, let’s help them do it.
Most people will doubt your judgment because of your age. It may take a lot more talking to convince the ‘adults’ that you really know who you are. -Chris, 19 (From the Advocates for Youth pamphlet, “I Think I Might Be Transgender, Now What Do I Do?”.)
*If anyone reading this has more information on endocrinologists who treat transgender youth in California, please private message me or include in the comments.
Gender Blog by Darlene Tando, LCSW 
Thank you, thank you, thank you. I’m so glad I survived and am now finally transitioned to my satisfaction. When I was 13, it would be twenty years before I even found the words to explain who I was and why I’d been hurting my whole life. Today’s kids have so many more options than I did. Let’s use them.
Thanks Darlene for being a great advocate to our kids!!! You are for sure saving lives.
Darlene, didnt you meet dr. Marinkovic recently. She is with radys children and just started a ‘gender clinic’ there. She is learning all of this as much as she can but is taking everything on a case by case basis and is giving cross hormones under age 16 when appropiate.
Hi Kathie,
Yes, I have met with Dr. Marinkovic. My hope is that we are (slowly but surely) moving in that direction down here in SD!
Warmly,
Darlene
Reblogged this on Trans*forming Family and commented:
A therapist’s view on treating transgender youth under the age of 16 with cross-sex hormones. We parents of trans kids face so much criticism for doing what we know is best for our kids, and it’s nice when folks with personal and professional experience in working with families like ours speak on behalf of our needs. Thank you for this wonderful piece, Darlene!
Dr. M at SD Children’s is wonderful; finally there’s an option for our kids locally. Darlene, once again, your compassion and good sense shine through. Much love to you!
Thank you!
We treat youth on the same informed consent model of care here that we do any adult. If a youth is old enough to understand their transition then with or without parental consent they can access hormones the same as any other young women wishing to access them for birth control or cycle control. Research shows young people as young as 14 have the same decision making abilities as any adult. Ontario, Canada
Excellent! I too believe in the informed consent model applying to youth and adults. Thank you so much for this input.
I can’t tell you how very very helpful your blog is to me. My name is Danyela Thurston. I am a MFT by trade and happen to have a transgender son named AJ who is 7 years old. Your insights and wisdom match our experience exactly and I just want to thank you from the bottom of my heart!! I meet Isaac’s mom last year at the Gender Odyssey Conference. Her words are so right on and when we transitioned AJ at the beginning of this school year I got to see a child I had never seen before. There was an indescribable light that glowed from everywhere inside of him when he went to school as his true self. I just think people can’t really get this until they see that glow. Thank you for your validation and depth of understanding for children like mine. With gratitude, Danyela
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Thank you so much for sharing, Danyela. AJ is lucky to have you!
In the UK, the Tavistock clinic has now a research programme. Those young people who pass the strict criteria would be given hormone blockers partway through puberty at Tanner stage 2 or 3 (depending on birth gender), which could be at 11-13 years of age. This suspends puberty for a couple of years, allowing some extra maturity, and further time for assessment, without the fear of being confirmed into an unwanted birth gender. Cross-gender hormones would be offered (we hope) a couple of years later. Those who do not fit the criteria would get blockers later, usually age 16, but this may hopefully be reduced soon.
I wish that the information and support had been there when I was going through puberty 30+ years ago. Many, many parts of my life would have been easier if I had been able to transition and live my entire life as my true self.
Thank you for this comment. That is precisely why I fight so hard for swift intervention for these teens! 🙂
Just discovered your blog and am so glad I did! I counsel transgender and gender variant clients in Colorado and gained a lot from this blog post. Thanks for all you do for this community…
Hi Dara,
So glad you enjoy my blog. I’m looking forward to visiting your website more as it develops!
Warmly,
Darlene
Hey Darlene, do you know of any transgender youth clinics in San Francisco? I’m 14. Also, thank you so much. This is exactly what I need to hear–progress.
Hi Jake,
You’re in luck! There’s a great one up there: http://www.ucsfbenioffchildrens.org/clinics/child_and_adolescent_gender_center/
Best wishes!!
Darlene
Hi Darlene,
Are you aware of any providers that share your viewpoint on Cross Sex HRT in the New York Metro area? I have a 14yr old who has been on blockers for a year and living in her affirmed gender for over 2yrs. She desperately wants to go through her “puberty” so she can catch up with her peers. I think she’s ready. Any referrals you could make would be greatly appreciated. Thank you!
Betsy
I don’t off the top of my head, but I will look into this!
Is Boston Children’s Hospital too far? Dr Norman Spack runs an excellent program for trans youth.
Hi Betsy,
I found a doctor in Syracuse who has and would provide cross sex hormones to a 14yo. Is that close to you?
Darlene
Would a 14 Year old be able to take Testosterone without parents permission? Or is that not legal?
I don’t think so. 😦 Sadly, current guidelines state parental consent as a prerequisite for those under 18.
[…] Click here for more information about cross-sex hormone therapy for transgender teens. […]
I’m an 18 year old transgender girl, I started hormones on my 18 birthday. I am currently 9 months on hrt! Dr Maja Marinkovic is my endocrinologist! She is amazing!
Congratulations!! That is so exciting!
Darlene,
LPCC with transgender client looking for endocrinologist in San Diego. Can you provide me with some referrals.
Thank you!!
Hi Roxanne,
Is this for an adult client? If yes, try
Dr. Neelima Chu
619-644-6815
or
Dr. Jeffrey Sandler
619-497-6188
Warmly,
Darlene
Hi Darlene, No I am sorry 15 year old. Thank you, Roxanne
Roxanne DeBell M.Ed,NCC,LPCC
This message, together with any attachments, is intended only for the use of the individual or entity to which it is addressed. It may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified that any dissemination or copying of this message or any attachment is strictly prohibited. If you have received this message in error, please notify the original sender immediately by telephone or by return e-mail and delete this message, along with any attachments, from your computer. Thank you. On Mar 2, 2016 9:11 PM, “Gender Blog by Darlene Tando, LCSW” wrote:
> Darlene Tando, LCSW commented: “Hi Roxanne, Is this for an adult client? > If yes, try Dr. Neelima Chu 619-644-6815 or Dr. Jeffrey Sandler > 619-497-6188 Warmly, Darlene” >
OK! Try the Gender Management Clinic at Rady Children’s Hospital
Dr. Marinkovic and Dr. Newfield
858-966-4032
Thank you so much!
Roxanne DeBell M.Ed,NCC,LPCC
This message, together with any attachments, is intended only for the use of the individual or entity to which it is addressed. It may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified that any dissemination or copying of this message or any attachment is strictly prohibited. If you have received this message in error, please notify the original sender immediately by telephone or by return e-mail and delete this message, along with any attachments, from your computer. Thank you. On Mar 2, 2016 9:22 PM, “Gender Blog by Darlene Tando, LCSW” wrote:
> Darlene Tando, LCSW commented: “OK! Try the Gender Management Clinic at > Rady Children’s Hospital Dr. Marinkovic and Dr. Newfield 858-966-4032” >
Hi, I’m currently working with a transgendered 14 year old who would like to transition to male and begin testosterone therapy. we have a very good working relationship and when we first met, i informed him and his mother that I have not worked with someone who wanted to transition, only adults who identified as transgender but did not transition, or who already transitioned. My client told me that when he was researching what steps to take, that the therapist has to write some kind of letter, i think giving the ok for the testosterone? This does not sound right to me and I would think this has to come from a medical doctor. Any help or direction to information? Thanks!
Hi Michelle! Thank you so much for researching this and contacting me. Your client is right! I have a whole host of information I can give you in regards to how to help your client access resources and interventions for transition. Where are you located? Please email me directly at tandotherapy@me.com. I will share with you general guidelines, the standards of care, and I can also share a sample letter.
Warmly,
Darlene