Notes from a Lecture: Hormone Therapy for Transgender Adolescents
I have several sets of lecture notes to write up from talks given at the larger workplace’s LGBT health week in March of this year. Yes, it has taken me forever to get to this – March and April have sort of gotten away from me somehow. As a result, some of my notes may not be as rich as I’d like, as they would be if I had converted them to posts right away, but I hope they’ll still be interesting and useful to readers. The followin is built from my notes on a presentation on Friday March 18, “Case Presentations in Adolescent Hormonal Therapy,” by Dr. Jennifer Najjar and Dr. Lisa Beavers.
Before we get into the lecture notes, I’d like to introduce the basic concept, although I am by no means an expert. One thing the speakers didn’t really get into was *why* you would want to delay puberty in transgender youth. Presumably they thought the mostly medical student audience would already understand the implications, but I think we’ll need to review this briefly here. While some readers may be completely unfamiliar with this concept and approach, coverage and discussion of the topic from the last few years can be readily found at outlets such as NPR, the New York Times, the LA Times, and Babble’s Stollerderby. Warning: offensive/transphobic framing, misgendering, assumptions (such as that sexual reassignment surgery is the only way to be a fully transgender person), language, and comments may be found in these pieces or their comments. They are included merely to illustrate “mainstream” or popular media sources paying at least some attention to this topic.
As you likely recall, many noticeable changes happen to the body during puberty – voices deepen, hair sprouts, breasts grow, menstrual periods start – physical markers that are typically strongly associated with one sex or the other. For young transgender people, these changes can be particularly problematic because they further expand the distinction between their physical bodies and their genders, and make it more difficult to be recognized as their actual gender.
Using hormones to block/delay these changes may reduce these difficulties, mental health concerns, bullying, and violence brought on by an enhanced dichotomy between physical sex and gender, allow a young person to transition his or her dress and name, and allow additional time for the adolescent and hir family to understand and adapt, including potential readying for further transition measures such as surgery once the adolescent reaches 18 years of age. This piece, Key to Successful Treatment of Transgender Patients May Involve Delay of Puberty, provides additional detail.
This approach also additional time for the adolescent to “be sure,” although I worry that this time for certainty is focused more on the needs of the parents/family and medical and psychological personnel as gatekeepers than it is for the needs of the actual young person.
As explained in the lecture, this puberty blocking is completely reversible, with puberty occurring as soon as the therapy is stopped. For further reading, try TransYouth Family Allies’s resources for healthcare providers, including Puberty Blockers 101, and TransActive’s medical resources. Suggestions for additional reading are appreciated in the comments.
Now, onto the actual lecture notes. These will be a little blocky, with my notes in brackets, but I didn’t want to do it all in bullet points.
Dr. Beavers indicated that she is the only practitioner in the state of Tennessee working with young transgender people in transition.
She indicated that in a year or so a new version of the DSM (diagnostic manual for mental health conditions) will be out, and the controversial gender identity disorder is likely to be replaced by gender incongruence. The criteria will include a lot of behavioral things like focusing on toys intended for the other sex, having a peer group primarily composed of the other gender [which sounds problematic in its own ways, but I'll want to see those criteria when they come out].
Dr. Beavers noted that endocrinologist Dr. Najjar is the only one who will work with her on transitioning young people and puberty-blocking. She said that this approach is not really outlined clearly medically or psychologically for practitioners. Transgender adults go through psychotherapy for one to two years with hormones before surgery can be considered [this is not uncontroversial in itself; see Julia Serano]. In the U.S. transgender young people cannot have surgery until they turn 18. In the past Dr. Beavers had to send families out of state before she was able to partner with Dr. Najjar.
The first case she spoke about (that she and Dr. Najjar worked on together) was a ten-year-old whose household family consisted of a mom, dad, and two siblings. She was first diagnosed with bipolar and attention deficit disorders. Her parents described her as having a behavioral desire to be the opposite gender, and this was creating family conflict. She was referred to endocrinology to check on her puberty status and endocrine issues disorders of sexual development, and was in family therapy for a couple of years before they started talking about stopping puberty.
At that point there was a question [there were questions throughout, rather than the end] about the girl’s school situation, which Dr. Beavers answered by saying the school situation depends on the people and the place – there’s no one answer for every young person. In one [or this?] case, the girl took a pink backpack to school and was bullied. Instead of stepping in and addressing the bullying, the school principal insisted that she should not have brought a pink bag to school [clearly a blame the victim scenario].
So when Dr. Beavers does therapy, especially when they talk about school issues, there is a lot of emphasis on safety. In this case the student was out of school in the initial part of transitioning and is now at a private school that is safe and that she has worked with. However, some kids don’t have the financial resources to switch to a private school that might be a safer change from their zoned public school.
Then there was a question about making the decision to transition and how to know its appropriate for the young person, to which Dr. Beavers replied that it is a very slow process, much slower than with an adult.
Dr. Beavers then referred to an NPR story “about 18 months ago” [I didn't find anything in that time frame, just the 2008 piece linked above]. She then talked about, especially in this area of the country, how transgender children are often treated by their families, with steps taken to take away toys and clothes that are really negative for the children. Their social ties and preferred activities may be severed by the adults, resulting in depression and anxiety for the children. She noted that a child may present with anxiety and depression, may be isolated, and may have parents and doctors who are pushing for further isolation of the child with resulting negative mental health consequences.
There was then a question about parents trying to “make” their child not be a transgender person, and discussion of how so-called “reparative” therapy is unethical and can be illegal. Dr. Beavers explicitly tells adults this when they raise the the idea in counseling sessions.
She explained that she tries to do initial talking and information-giving early on and build trust, providing ethical and accurate information, but parents still my not accept it, it can be a long process for them adjusting to what it means to have a transgender child. Dr. Beavers said that she has worked with parents who wanted to have an exorcism [!] for their child; she tries to explain to them why that won’t work and what negative consequences will happen for them and their child.
She noted that it was just two years ago that “reparative” there was deemed inappropriate, that the Academy of Pediatrics has statement or policy out on sex and gender, and the American Psychological Association has followed suit [I don't think I'm finding the right things on these, need to keep looking].
The “One in Teen” group was mentioned as a local resource, although it should be noted that this is a broader LGBTI group, not specifically for trans youth. She noted that beyond this one resource, it is a real problem for transgender youth to find safe same-age peer groups (noting the lack of safety for participating in sex-segregated sports teams, etc.). She also referred to a conference in Pittsburgh each year [couldn't find it - wish we'd had a handout of links/resources!] and trans-friendly summer camps [perhaps like this one].
Next up, Dr. Jennifer Najjar, pediatric endocrinologist spoke. She stated that there is a lot of research to back up the idea that gender identification in the brain can be very different from the physical presentation. She said that as part of her professional work she also consults for the psych hospital, and so has been asked to see children with gender identity issues who do not have traditional endocrine disorders.
She emphasized that there is a program that Dr. Beavers works through with children and their families before figuring out the appropriate medical path. She also explained that blocking puberty can be reversed can happen before or after puberty starts. She then went into the specific hormones used in this therapy, and my notes are error-laden enough and endocrinology is complicated enough that I don’t feel completely confident in my notes. I believe she said the primary hormone used is an agonist of hypothalamic hormones, they stimulate the pituitary, use spironolactone if they are seeing some puberty to reduce the physical signs, and may use some oral estrogens.
She said that one of the most difficult problems is social rather than medical, that the social skills acquired in puberty are lost for a while – patients they have and eighteen year old body but social adjustment may be delayed because they may (after stopping therapy) have a newly pubertal body and the issues that go with that that would normally be done at thirteen or fourteen.
She indicated that gender identity is ingrained from a very young age, sometimes less than a year old. She also noted that it is very hard to get insurance to cover the therapy; she has had very little luck with insurance until lately when she has put the transgender diagnosis code on the paperwork and insurance actually covered it. However, providers have to consider how explicitly to document very carefully. For example, if somebody goes in to get an appendectomy, at that point insurance may get the whole chart, with all of the transgender documentation in there. They don’t need it for the appendectomy, but the system is such that they can find that out at that point.
That was basically it – I think the audience probably had a lot more questions but there wasn’t time to get them all answered. I asked Dr. Najjar about whether she ever has issues where the young person approaches her for treatment and the parents aren’t on board, and whether the parents have to consent for that. She indicated that the patients don’t ever really come to her directly, they all get referred to Dr. Beavers first and don’t come to her until after they have been through the therapy there. It wasn’t entirely satisfying, because I’m still worried about this “gatekeeper” issue and what happens to transgender children when the parents are a-holes. Overall, though, it was an interesting discussion of issues I think that a lot of medical students don’t get a chance to get exposed to.