New guidelines for teens with Gender Identity Disorder

by Kristin Cantu on September 24, 2009

androgynous kidGroundbreaking new guidelines about how to treat children with Gender Identity Disorder have been issued by the Endocrine Society. They suggest that at the first signs of puberty, physicians delay the onset of puberty and wait until the child is approximately 16 to begin any sort of hormone therapy involved in a gender transition.

Norman Spack, MD, co-director of Children’s Gender Management Service Clinic, is a part of the team that wrote these guidelines. We spoke with Spack about the guidelines and the history of treating children with Gender Identity Disorder.

According to Spack, puberty suppression is not a new idea. The early standard of care for individuals with Gender Identity Disorder started with the Harry Benjamin International Gender Dysphoria Association, more recently known as the World Professional Association for Transgender Health. The early standard of care was a method of pubertal delay that involved the use of progesterone, either in high dose oral daily form or through depot injections to shut down puberty, Dr. Spack said.

In the 1990s, the Dutch improvised on a method to block puberty via GnRH agonist injections, which had been shown to be safe and successful in treating central precocious puberty beginning in the 1970s during procedures given at Children’s and Mass. General Hospital.

Spack says that since boys and girls have similar body shapes and bone structures until puberty, you can more easily “keep kids in limbo at that age.”  Spack doesn’t believe lifelong decisions should be made in 10-12 year old genetic girls and 12-14 year old boys. Later in adolescence, if a decision is made to block the unwanted puberty, the affirmed gender can be hormonally provided after intensive psychological testing.

While these new guidelines do represent a step forward in treating Gender Identity Disorder, Spack believes that the real problem associated with it is that it is classified as a mental illness. “As long as it’s stuck in the manual under that classification, insurance will only pay for counseling leaving families to pay for expensive medications and surgeries,” Spack says.

The manual Spack refers to is the Diagnostic and Statistic Manual of Mental Disorders, the same one where homosexuality was classified as a mental illness until 1973. “There is a huge fight over whether Gender Identity Disorder can be removed from the manual,” he says.

The treatment suggested in the new guidelines for children with Gender Identity Disorder is costly. “GnRH agonists to suppress puberty can cost around one thousand dollars a month and may have to be used for two to four years,” Spack says. “If they get transgenderism out of the manual, it will hard for insurances companies to deny coverage for a condition that even the previously conservative Endocrine Society is now regarding as a medical diagnosis meriting endocrine treatment.”

In today’s world, “younger people consider this situation an affront to human fairness and decency,” he says. “It’s historic that the Endocrine Society, the oldest and largest organization of endocrinologists in the world, would do this.”

12 comments

  • Mark

    Simply vulgar! Shouldn’t we be trying to reconcile the mental perception of a child with his/her biological sex? We should promote the positive aspects of their sex and encourage them gently to develop correctly. This treatment denies the person the ability to reproduce.

  • Mark

    Simply vulgar! Shouldn't we be trying to reconcile the mental perception of a child with his/her biological sex? We should promote the positive aspects of their sex and encourage them gently to develop correctly. This treatment denies the person the ability to reproduce.

  • Erica

    Mark, if you were to wake up tomorrow as a biological woman, would you prefer to have your sex corrected to your mental perception, or should your mental perception be matched with your biological sex? This is the same situation transgendered people, adults and children alike, are in. They feel as much male or female as you or anyone else, it just does not match their biological sex. Their perception of who they are cannot be changed any more than your own can, nor do you or anyone else have the right to demand it be changed. Also, this procedure absolutely does not deny a person the ability to reproduce. If, at age 16-18 they decide they do want to go through puberty as their biological sex, they will when treatment is stopped. This treatment is a major step forward in both culture and medicine.

  • Justine

    Most people will simply never understand this unless they see it in one of their own family members. I have a son who has exhibited this behavior since the age of three, and there is nothing you can say to make him like “boy” clothes or things. I try to explain it to people by asking them to imagine being a child and being told they weren’t allowed to play with the toys they liked or wear the clothes they liked, and they just get a blank look, like “so what”? The ignorance and hostility will continue into the foreseeable future. I wish we were able to afford this treatment for my son, but it’s just impossible.

  • Red

    Obviously you have never personally dealt with children like this, nor have a child with these issues, PLUS you completely read the article WRONG. The purpose of the puberty blockers for most children is TO SUSPEND PUBERTY, giving them time to receive therapy from psychiatric professionals. Because many of these children have body dysmorphia (look it up) they are greatly distressed and upset by their bodies changes. Blockers stop the changes. Allows them to focus on normal life processes and receive the emotional and psychological help they need to learn to live with themselves, no matter what gender they decide to be in the end.

    If they choose to continue the blockers and later have cross-sex hormonal treatment they can do so. IF they decide they wish to remain in their “outward” gender, the blockers are stopped and PUBERTY PICKS UP WHERE IT LEFT OFF. There is no change. No damage.

    The suspended time is critical for the majority of children and adolescents whose rates of mental distress and/or suicide attempts or successes when their needs and feelings are ignored, or as you suggested, subsumed under someone else’s personal opinions of what is correct.

    Certainly any child should be treated positively and encouraged in what is BEST FOR THEM. What you suggest Mark is taking away their choices to fit your own idea of what you think is best. That is the very attitude which drives so many children and young people to negative behaviour or suicide. Their needs and desires are ignored. And btw the reproducing is not the penultimate goal of everyone, and in no ways proves anything positive about them. Keeping a child, a young person ALIVE is what is most important, and if this is what keeps them alive and able to be happy, then that is what POSITIVE people or parents will do for the children, not force them into a life long sense of misery, or a short life of pain and shame before they end that life themselves.

  • Red

    Obviously you have never personally dealt with children like this, nor have a child with these issues, PLUS you completely read the article WRONG. The purpose of the puberty blockers for most children is TO SUSPEND PUBERTY, giving them time receive therapy from psychiatric professionals. Because many of these children have body dysmorphia (look it up) they are greatly distressed and upset by their bodies changes. Blockers stop the changes. Allows them to focus on normal life processes and receive the emotional and psychological help they need to learn to live with themselves, no matter what gender they are.

    If they choose to continue the blocker and later have cross-sex hormonal treatment they can do so. IF they decide they wish to remain in their “outward” gender, the blockers are stopped and PUBERTY PICKS UP IMMEDIATELY WHERE IT LEFT OFF. There is no change. No damage.

    The suspended time is critical for the majority of children and adolescents whose rates of mental distress and/or suicide attempts or successes when their needs and feelings are ignored, or as you suggested, subsumed under someone else’s personal opinions of what is correct. Certainly any child should be treated positively and encouraged in what is BEST FOR THEM. What you suggest Mark is taking away their choices to fit your own idea of what is right and proper. That is the very attitude which drives so many children and young people to negative behaviour or suicide.

  • Alex

    Poor kid. I hope everything works out okay!
    My friend is transgendered and forced into the closet by his parents. After seeing how upset he is, transphobes make me really, really angry.

  • Becky

    “Mark, if you were to wake up tomorrow as a biological woman, would you prefer to have your sex corrected to your mental perception, or should your mental perception be matched with your biological sex?”

    What a ridiculous notion! “Transsexuality” is based on the same science-fiction as waking up another sex. Most people accept the gender they are, whether they like it or not, and just get on with life without making a fool of themselves. Children should be taught to be proud of themselves. Changing sex negates this statement and makes them believe they were “born the wrong sex” when in fact there was nothing wrong but their perception. Medicine should be used to treat the sick, not to pander to the perverse parphilia of deviants.

  • Diane

    My sixteen year old son is transgender. She is now living as a female. We have been blessed to have insurance that will pay for the monthly Lupron injectons, and the estrogen. Our child shared that she was transgender two years ago with us. We always knew that she was different. We are totally supportive. She sees a psychologist twice a month, and an endocrinologist every three months. We had a difficult time finding a doctor that would treat her because she was underage. This has been a journey that we are traveling together. It has not been easy. We accept our daughter, and love her. She is a beautiful person. She is healthy. She is not always easy to live with. We try to keep in mind all that she is going through from her perspective, and be patient.

  • Gbchhc

    How sad that these poor people are led down the garden path by so called experts as Dr. Spack. This doctor has zero supporting evidence of an objective nature to support this mutilating approach and is a self promoting physician wo is more interested in his notariety than anything else. Before this type of therapy can be performed it would take many years of careful research. Other noted hospitals have already done that and come to the conclusion that gender reassignment surgery is wrong in that it corrects a psychological disorder with a physical fix and that the long term outcome is poor. They feel the focus should be on psychological research and treatment since the surgical approach attacks a healthy body. See the Johns Hopkins experience. Parents support these type of programs initially because they seemingly brings relief , however, many transgendered people go on to depression, regret , and suicide, and then those parents recant. I hope this man can be stopped before he causes the unnecessary mutilation of many more children who are having these decisions made before they are ready to be responsible themselves.

  • guest

    Transgendered children certainly have a very hard time of puberty, but many other children might benefit from this choice. Children with mental illnesses or other difficulties could have some more breathing space to mature in with the option to delay puberty. Coping with menarche can push an already stressed child over the edge. As someone who was born female and has never really identified with either gender all my life, I can say that I would have much preferred not to go through puberty at all. ‘Becoming a woman’ ruined my career: I developed a disease of the reproductive system (endometriosis) that caused me pain and made it increasingly difficult to do my work. I was eventually made redundant and am now unemployable. I did not ask for reproductive organs; I have never tried to use them. There are enough people in the world. I asked for a career, and it was denied because of society’s idea that people must be slotted neatly into categories of male and female with all the accompanying inconvenience.

    It’s seen as responsible and proper to spay or neuter pet animals, but seen as improper and aberrant for a child to want a totally reversible version of this. I think this treatment should be available on demand for any child who asks for it.

  • Razertechnologies

    I’m different and am not traditionally masculine as many guys would portrait it but it doesn’t mean I’m a woman stuck in a man’s body.  

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