How Young is too Young?

One of the great dilemmas in treating children whose neurology is cross-sexed to some degree is that the pubertal clock is ticking. Children become pubescent before their brains have developed adequately for them to be judged competent to make decisions as an adult.

This leads to laws about "statutory rape" of adolescents, where although their reproductive systems may be physically developed, their intellect and ability to make informed decisions hasn't caught up. This is partly due to inexperience - innocence - but also due to incomplete neurological development.

From the Herald-Sun:

A Court has allowed a 10-year-old boy (girl-ZEB) to become the youngest Australian to have sex-change therapy.

The boy (girl-ZEB), known as Jamie, has lived as a girl for two years, dressing in feminine clothes, using the girls' toilet at school and "presenting as a very attractive young girl with long, blonde hair", the court heard.

Jamie's parents, medicos and psychiatrists feared early-onset puberty could lead to self-harm or suicide and supported an urgent application for the child to receive sex-change therapy.

Family Court Justice Linda Dessau ordered that Jamie be allowed to start drug therapy to stop male puberty and that the court reconvene when she turned 16 to consider approving the second stage of taking female hormones to feminise the body.
...
A medical expert said when he first saw Jamie in February 2009, she "looked convincingly female in every way" except her genitalia.

The doctor said he was concerned about Jamie's rapid-onset puberty, which was equivalent to that of a 14-year-old, and that sex-change treatment should start immediately.

Sometimes Nature rushes us. 10 is too young to make a decision. But we have to guess what the right thing is to do here. Get it wrong one way, she may die, and will have entirely preventable problems her entire life. Get it wrong the other way, and we have interrupted the natural development of an effeminate gay boy, who may be just as happy living that way.

The best guess we have is to let puberty start, to let the child get a feel for it. If they react in utter horror, if symptoms of distress significantly worsen, then allow administration of puberty-delaying drugs. This is not a simple, clear-cut issue, many Gay and Lesbian advocacy groups think that we should let the brain develop naturally as puberty progresses, that we may be creating transsexuals out of gays. Not surgically, but by interrupting the natural neurological development process. They point out that mere gender non-conformant behaviour when young is usually a symptom of future homosexuality, not transsexuality. We can argue whether 20% or 35% of such children are transsexual[1], but there's no argument that 2/3 are gay or bisexual, not transsexual. It's complicated by the fact that many of those advocating a moratorium on treatment want all transsexuals to die on ideological grounds, and have said as much. One therefore might suspect their motives here,but what matters is not the motives, it's whether they're right or not.

The thing is, we don't allow treatment based purely on gender non-conformant behaviour of short duration, which is what pre-gay children exhibit. Or at least, we shouldn't. Given the general lack of knowledge in the medical profession in this particular area, it sadly wouldn't surprise me if a few incompetents did.

Here's the definitive paper on the subject:

Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects-- Delemarre-van de Waal and Cohen-Kettenis 155 (Supplement 1): S131 -- European Journal of Endocrinology.

First, patients were considered eligible for a staged hormone treatment if they were (i) between 16 and 18 years, (ii) suffering from life-long gender dysphoria that had increased around puberty, (iii) functioning psychologically stable, and (iv) supported by their environment.

Since the experience of a full biological puberty may seriously interfere with healthy psychological functioning and well being, we have changed our protocol after the first follow-up studies on the 16–18-year olds (4, 5). Adolescents are now allowed to start puberty suppressing treatment with gonadotrophin-releasing hormone analogues (GnRHa) if they were older than 12 years of age and fulfil the same criteria as were used for the 16–18-year olds. They should also have reached Tanner stage 2 or 3 in combination with pubertal levels of sex hormones. The suppression of puberty using GnRHa is a reversible phase of treatment. This treatment is a very helpful diagnostic aid, as it allows the psychologist and the patient to discuss problems that possibly underlie the cross-gender identity or clarify potential gender confusion under less time pressure. It can be considered as ‘buying time’ to allow for an open exploration of the SR wish.

It is conceivable that lowering the age limit increases the incidence of ‘false positives’. However, it most certainly results in high percentages of individuals who more easily pass into the opposite gender role than when treatment commenced well after the development of secondary characteristics. This implies an improvement in the quality of life in these individuals, but may also result in a lower incidence of transsexuals with postoperative regrets or poor postoperative functioning. Clinically, it is known that some patients who were treated in adulthood regret SR because they have never been able to function inconspicuously in the opposite gender role. This holds especially for MFs, because beard growth and voice breaking give so many of them a never disappearing masculine appearance. But, since the number of ‘false positives’ should be kept as small as possible, the diagnostic procedure should be carried out with great care. Until now, no patients who started treatment before 18 years have regretted their choice for SR.

Jamie, the girl in Australia, would not have qualified. She would have had to wait another two years - and as her pubertal development was already that of a 14 year old, the consequences would have been grave. As in, quite possibly fatal, and leading to lifelong misery.

Had such treatment been available in the 1960's, I would not have qualified either. I showed little or no gender-nonconformant behaviour at the time. I was polite, biddable, shy, emotional, but I wanted to play with trucks and spaceships, not dolls. I was also extremely determined, quite happy to die in the attempt if it meant I succeeded, or that was the only chance of success. I didn't "know" I was female at age 3 or 4. It was only through a process of deduction that I realised it, and not before age 7. The process was complete by age 10. The re-think and re-evaluation when I learnt a bit more about biology a few years later never shook that knowledge. I never managed to convince myself completely that I was male, and goodness knows, I tried.

We're talking about extreme cases here. The so-called "Primary Transsexuals", far more strongly neurologically sexed than most humans. They literally cannot function as the opposite sex, the complete opposite of the many who are bi-gendered, who can.

From the UK Telegraph:

Nicki was born a boy but as early as 18-months-old, she was already trying on her mother's dresses and underwear.

At nursery, she shunned boys' games and preferred to play with the girls.

By four, Nicki was telling her mother Sharon, an IT manager, that "God made a mistake by making me a boy".

Two years later, she was already asking for a sex change operation.

See the difference? You can recognise these cases a mile away. They're nothing like me, I survived till age 47 without treatment. They can't make it past 25. Many don't make it to 20.

"She got quite a lot of stick because she was going to school as a boy and saying she was a girl.

"So, at eight, we made the decision not to let her do that.

"I let her grow her hair and she got a blouse and a skirt. She didn't have to wear boys' clothes at all anymore.

"As soon as I did that she was so much happier and the other kids understood it because she looked like a girl now."

But matters took a turn for the worse when Nicki moved on to secondary school, where she became suicidal because of bullying.

"She took four overdoses," said Sharon, from Yorkshire.

"For a year and a half she was spat at, kicked, punched, pushed over.

"One day, when she was walking home from school a group of boys surrounded her and tried to pull her skirt down."

"When she first got to the school, one boy announced 'So where is the tranny?' It was awful."

With the abuse expected to get worse as Nicki got closer to puberty, her mother began to look into the possibility of her daughter being prescribed hormone blockers.

She went back to the Tavistock clinic but was told they were unable to prescribe the treatment because it was against their guidelines to do any interventions before 16.

Fearing that her daughter may take her own life if forced to go through puberty, she went to an American expert Dr Norman Spack in Boston.

To her relief, Dr Spack, who runs a Gender Identity Disorder clinic in Boston, agreed to prescribe the 13-year-old Nicki the blockers.

Now 17, she has had a sex change operation and works as a care assistant.

"She holds down a full time and has been with her boyfriend for 18 months and she is gorgeous," said Sharon.

"I am absolutely positive she would not be here without the treatment."

I've seen one of Norman Spack's patients. Breathtakingly lovely, an elphin beauty, a girl who has had little psychological damage from her unusual biology. Some though. We can only reduce the harm, not prevent it, not without changing society. We can start though by legalising the best kind of medical treatment that we know of. Again, from the UK telegraph :

Until this month, British doctors were prevented from offering youngsters diagnosed with gender issues any medical intervention before the late stages of puberty usually at 16.

But now the National Research Ethics Service has given approval to the UK's only specialist clinic for GID – the Tavistock and Portman NHS Trust in London – to prescribe the drugs to youngsters from 12 years old.

Dr Polly Carmichael, the clinic director, said the reduction in the age limit will be welcomed by families who would have otherwise had to travel abroad to the US for the treatment.

"The majority of our referrals are 15-plus and we get fewer from a younger age group," she said.

"Certainly, of the children between 12 and 14, there's a number who are keen to take part.

"I know what's been very hard for their families is knowing that there's something available but it's not available here.

References:
[1] Psychosexual outcome of gender-dysphoric children.Wallien MS, Cohen-Kettenis PT. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23.

At follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric.