Should There Be a Minimum Age for Gender Transition?

In an interview with Endocrinology Advisor, Jason A. Klein, MD, a pediatric endocrinologist at Hassenfeld Children’s Hospital at NYU Langone in New York City, described his process of evaluating pediatric patients with gender dysphoria as congruent with current standards of care.

“It depends on what age they are first coming to see us,” he noted. “At [our] Transgender Youth Health Program, we see young children who are prepubertal through [those] who have completed some degree or all of puberty and are seeking gender-affirming care.” Dr Klein stated that, regardless of age, all care is delivered in a personalized way to meet the needs of the patient and their family.

“Not every single transgender or gender nonconforming or nonbinary person needs the same amount of or types of intervention,” he added.

The Endocrine Society Guidelines recommend that mental health providers who are well versed in child and adolescent developmental psychology and psychopathology spearhead the process for patients.10 These providers, ideally, would be on hand to distinguish between patients with gender dysphoria or gender incongruence vs other conditions with similar features, like body dysmorphic disorder. After this initial evaluation, as well as counsel about fertility preservation, referral for appropriate treatment may be provided.10

Even for patients seeking only to transition socially — those who are prepubertal, for example, for whom puberty blockers and gender-affirming hormone treatment are not recommended — the guidelines suggest that experienced professionals become involved in the process.10

Dr Klein emphasized that one of the most important aspects of providing care at this juncture is simply understanding. “One of the first things that we do when we see a new patient is find out that patient’s story. Do they consider themselves transgender? Is there something else that they consider themselves? What has been their experience in terms of social transitioning? What are their short- and long-term goals?”

According to researchers, decisions regarding hormone treatment or surgery vary greatly from patient to patient and are extremely individualized — similar to the way a person’s gender identity is individualized.

Much of the concern stemming from the Texas case seems to result from a proliferation of general inaccuracies with regard to existing research. In late October 2019, Republican Representative Matt Krause tweeted his plan of action to #SaveJamesYounger: “…I will introduce legislation that prohibits the use of puberty blockers in these situations for children under 18. We missed our opportunity to do so in the 86th [Legislative] Session. We won’t miss the next one.”

However, Representative Krause’s push to legislate access to puberty-blocking treatments is not aligned with the Endocrine Society’s scientifically backed recommendations. In fact, when treating adolescents, the Society suggests that suppression of pubertal development should be the first course of action “after girls and boys first exhibit physical changes of puberty.”10 This means, Dr Klein noted, that Luna Younger would not even be eligible for medical intervention.

“Part of the requirement [for pubertal blockers] is that you have to be in puberty. There has to be something to block,” he said, citing the 2017 Endocrine Society guideline. “[Patients] have to be at Tanner 2. For kids who are not there yet, what we recommend is to potentially transition socially, and open up the so-called gender norms to figure out what they like.”

In a 2018 policy statement, the American Academy of Pediatrics shared a similar recommendation.11

“Gonadotrophin-releasing hormones have been used to delay puberty since the 1980s for central precocious puberty,” wrote lead author Jason Rafferty, MD, MPH, EdM, FAAP, a pediatrician and child psychiatrist at the Adolescent Healthcare Center at Hasbro Children’s Hospital in Providence, Rhode Island.11 In adolescents with gender dysphoria, these hormones can “provide time up until 16 years of age for the individual and the family to explore gender identity, access psychosocial supports, develop coping skills, and further define appropriate treatment goals.”11

In addition to these benefits, Dr Rafferty noted that pubertal suppression typically offers patients an opportunity to reduce the distress associated with secondary sexual characteristic development that is incongruent with the patient’s lived gender.11

Despite scientific evidence and existing clinical practice guidelines, critics also remain in the medical community. According to results of a poll hosted on Sermo, a global social platform for physicians, 94% of physicians think that an age minimum is an appropriate benchmark for patients who wish to transition: more than half (62%) of these respondents said that the minimum age should be 21 years, while nearly a third (32%) said that age 18 years would be an appropriate minimum.

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While many countries recognize 16-year-old patients as legally competent to make medical decisions, others believe that abilities such as good risk assessment do not develop until after age 18 years.10 The Endocrine Society guidelines state that gender-affirming treatment in the form of sex hormones may be initiated “after a multidisciplinary team…has confirmed the persistence of [gender dysphoria]/gender incongruence and sufficient mental capacity to give informed consent,” which is typically around age 16 years.10 Some research suggests that there are risks associated with waiting until as late as age 16 years, and more long-term studies are needed to determine the optimal age for treatment.

On Sermo, one endocrinology physician shared a belief that children and adolescents do not possess the capacity to make informed decisions about fertility or permanent body alterations. “Affirming a child’s false gender identity, instead of providing exploratory counseling to help resolve the dysphoria, is astonishingly negligent.”

Another physician, specializing in physical medicine and rehabilitation, agreed. “Children [do not] know enough about themselves to be trusted to make the correct, irreversible decisions, and generally do not have the maturity to handle it. More kids question their gender now due to it being popular socially, or more in the news and social media. We cannot allow them to be potentially permanently harmed for a potentially temporary condition.”

This is a sentiment with which Dr Klein strongly disagrees.

“Trans people have been around forever,” he said. “This is not an invention of the aughts. People have been [providing] care in trans communities for decades now…and finally there are formalized guidelines…and people are feeling more comfortable expressing their gender truthfully and are feeling comfortable enough to do something about it.”

Although transgender people may now feel safer to publicly express their gender, some lawmakers are creating policies that have the opposite effect. Since taking office, President Donald J. Trump has made efforts to roll back many of the steps undertaken by the Obama administration to bring equality and protection to the transgender community under federal law.

In 2017, this included the removal of protections that allowed transgender students to use bathrooms that corresponded with their gender identity.12 In 2018, it took the form of the Trump administration attempting to narrowly redefine the concept of gender as “a biological, immutable condition determined by genitalia at birth,”13 or essentially, as one New York Times article stated, defining the word transgender “out of existence.”

Most recently, the Trump Administration moved to repeal Obama-era protections that banned discrimination against transgender patients in medical settings and as health insurance customers.14

These legislative maneuvers, coupled with the recent statements from Texan legislators about the Younger case, have left some within the medical community concerned. The Pediatric Endocrine Society, for example, has called out the recent “public discourse” as potentially harmful to the wellbeing of both transgender and gender-diverse children and their families — and in opposition to the current standard of care.15

“[W]e strongly oppose public discourse that misrepresents and contradicts evidence-based standard of care recommendations and risks the [wellbeing] of transgender youth and their families,” the statement read in part.15

According to the American Academy of Pediatrics, those risks can range from depression and anxiety to eating disorders, self-harm, and suicide.11

“We know that our transgender kids, especially children and adolescents, have a much higher risk for and rate of self-harm and of suicidal thoughts or suicidal attempts, and of depression and anxiety — especially those who are not affirmed within the home or school, ” said Dr Klein. “It is not so much being transgender that causes depression…alcohol and drug abuse, anxiety, [or] things like that. It is really being unaccepted that does that.”

This article originally appeared on Clinical Advisor