International Endocrine Society: Block Puberty in Kids with Gender Questions
Things continue to go from the strange, to the surreal. The International Endocrine Society is advocating that drugs be given to children with gender identity questions to block puberty, which is already done in some places. From the story:
Let me get this straight. We are going to interfere with a child's biology due to a his or her severe emotional confusion--the seriousness of which I am not denigrating--and basically use medicine to transform a healthy body into one that doctors would treat as an illness if it occurred naturally? Doesn't that about sum it up?Transsexual children as young as 12 should be given drugs to postpone puberty and make it easier for them to change sex at the age of 16 if they still want to. That's the suggestion of controversial draft guidelines, the first of their kind, issued last week by the international Endocrine Society.
The guidelines state that transsexual children and young teens who have begun early puberty should be given puberty-blockers to avoid inevitable changes to their bodies, which they perceive as out of line with their true gender. In the worst cases, these changes can drive children to self-harm or even suicide. The idea is to buy thinking time for young people so they can decide if they want to begin a sex change using hormones when they are older...However, surgery should be avoided until the age of 18, the guidelines state.
This is getting into very deep and turbulent waters:
But doctors opposed to early treatment say that young people may not fully understand the full consequences of their actions. For example, blocking puberty in boys who later go on to have hormone treatment and surgery that turns them into a woman means that they will never produce mature sperm...Russell Viner of the Institute of Child Health in London cites the case of a transsexual man who had both surgery and hormones to become a man, but still wanted to become pregnant. "That may not have been possible if they'd had early intervention," he says. "When is it reasonable to let a young person remove major life choices?"Remember the "man" who gave birth that Oprah cooed over?
More to the point, what have we come to when doctors urge that natural and normal physical development be blocked? (Remember "Ashley's Treatment?") Do we know what the impact of such heavy hormonal interference will be on the health of these young people both long and short term? Do we know what psychological impact it will have? If not, doesn't this border on unethical human experimentation? This is how we are twisting ourselves into pretzels from a mindset that cares almost entirely about subjective internal states.
In this regard, an editorial in the New Scientist about this story made some good points:
...some 80 per cent of boys who experience transsexual feelings no longer feel this way when they grow up. There is some evidence that those who persist after the first flush of puberty are less likely to change their minds, but this has been based on a handful of cases. So too has our understanding of the side effects of delaying puberty--or in the case of those who go through with gender reassignment, preventing natural puberty from occurring at all.If we are going to let doctors intentionally create unhealthy biological abnormalities in patients, where will it stop? When Body Identity Integrity Disorder sufferers point to things such as this and sexual reassignment surgeries, do they not have a point when they say, "If a child's normal biological development can be arrested in preparation for removing his or genitals, why can't I, as an adult, have my right arm amputated?".
The issue becomes thornier still when you consider that the age of puberty is falling. Does, say, a 9-year-old have the emotional maturity to make a decision of this magnitude? Unlikely. Intervention to delay puberty could even be complicated by a broader issue: the possibility that the sexualisation of children at ever-younger ages is raising the numbers with temporary transsexual feelings.
Step-by-step and inch-by-inch we get closer to harming people in the name of helping them.
posted by Wesley J. Smith @ 1:37 PM
23 Comments
23 Comments:
Doesn't John Hopkins refuse to do transgender surgery on the grounds that it is a mental illness that has no physical treatment, but rather requires psycotherapy?
It is insane that doctors would regard this blocking of the development of puberty as something that 'holds at bay' the person's sex, as if the person was neutral up that point.
The person's sex is already there.
The other scary thing is that they regard it as buying the developing child 'thinking time'. Anyone with common sense can see that blocking the development of puberty for the purpose of consideration for a future sex-change is nothing other than enforced lock-step; lock-step towards insuring that the child will indeed follow through with his or her disorder.
How can the child make a "fully-informed" decision when he or she has not even experienced the development of puberty to measure against?
They wouldn't be able to do this without experimentation on non-human animals, then? They wouldn't have thought of it otherwise. Messing with them leads to messing with us. I've more sympathy for the lab animals than for the gender-confused, whether it sounds harsh or not. Somewhere along the line humans got the idea that they're entitled to whatever they want. Life isn't easy and it isn't supposed to be.
I doubt they have done that. How many animals are transexual?
The more I think about it, the more unethical this becomes in my mind.
What I mean is that the "scientific and medical advances" that experimentation on non-human animals has "given us" and to which humans feel entitled are what made this proposal possible, and that messing with non-human animals has led to messing with human ones. I didn't mean that they have done this on transsexual non-human animals. Of course it's unethical! But God forbid humans should leave what God has created alone. That's part of my difference with human exceptionalism.
I don't know how many non-human animals are transexual in nature, if any are, but I doubt that researchers haven't been trying to create transsexual animals in the lab for study and experimentation purposes, or that they haven't thought of it. As for harming people in the name of helping them, I think we're long past having gotten to that point, long past there. Not to mention that euthanasia and assisted suicide also fall into that category.
I would certainly say that amputating healthy human genitals is at least as crazy as--probably crazier than--amputating a healthy human limb. If I'm not mistaken, the "sex-change surgery" came first and the "body identity" surgery came second. And no doubt that is _exactly_ what the seekers after limb amputation said.
This is a truly crazy trend. Notice the reference to the young people _as_ "transsexual children" in the story. So already that is being treated as part of their intrinsic identity, as if it said "black children" or something like that. The effect of such verbal uses cannot be overestimated, I'm inclined to think. Once the child is identified as "transsexual," the game is pretty much over, isn't it?
I agree that using hormonal treatment to arrest puberty, unless it is forestalling something life-threatening I haven't thought of, is wrong. I think its wrong because fooling with the complex interrelations of human hormones without more information is always a bad idea and almost invariably leads to trouble. It is also wrong because, as was pointed out, what is a transsexual child? That isn't even meaningful, unless we accept sexual/sexualized children, which I don't think we should.
The other problem I see is that we, as a culture, do not have a good response to transsexuals. I'm not one, but I believe that there are people out there who are a different gender internally than what they are physically. I don't think we have anything helpful to say to them. I don't think "You are wrong and we will fix you" is helpful loving, or ethical, and I don't think "We will give children hormone treatment so they can decide on surgery years later" is helpful, loving or ethical either. The first one is, frankly, the conservative one I hear far more than any others, and the second, from this post, is one I've never heard before, but is alarming, from the far left.
I wish we had some sort of third response that acknowledged the dignity and autonomy of transsexuals while also not potentially damaging children who, as it was pointed out, are both vulnerable and easily influenced.
Humans already do crazy things that mutilate the human body. This is an example of what happens when one starts down that road. As for some sort of third response, I suppose telling the kid well kid sometimes what is happening with you happens in nature no one's life is perfect now eat your spinach.
I had a book called AS NATURE MADE HIM: THE BOY WHO WAS RAISED AS A GIRL.
Twin boys were born to a couple, and one of the boys had a botched circumcision that destroyed his exterior sex organs. One doctor found this a great way to experiment, so he told the family to have him sexually reassigned.
The boy was rasied as a girl but hated it, and eventually found out that "she" was really a "he." He then went on to get reconstructive surgery and lived out the rest of his life as a man.
The kid was given all kinds of hormonal treatments to turn him female, and his biggest complaint as an adult was that he'd suffered so much from his ambiguous identity that he suffered severely.
There was also an interview with another patient (this one an adult at the time of the book's writing) who was born a boy and raised a girl for similar reasons. Although she lived her life as a female, it's obvious in her dialogue that she isn't happy or comfortable with it but feels there is no way around the sex change.
You can't play around with the human body like that. It just makes the kids in question suffer. Delaying puberty is a lot like what the title character went through, and his only relief was in stopping the treatments and living like a boy.
A couple of thoughts on this subject:
(1) GID is a serious mental health issue for those that suffer from it - especially during the adolescent and teenage years.
(2) Suicide and self-harm is fairly common among transsexual youth. Often this is a direct response to the changes that puberty causes.
(3) I would urge you to read the WPATH Standards of Care carefully. It quite specifically advocates caution in the treatment of non-adult patients.
(4) I do agree that there are all sorts of long term questions around the puberty blocking treatments. (I've expressed some of my concerns in more detail here). However, those questions can only be answered in time - it will be decades before we can actually assess whether youthful transition (pre-puberty) is successful for these children or not. Certainly, the evidence is that the younger someone transitions, the easier it is for them to 'fit in' to society normally.
(5) T.E. Fine: Colapinto's books is an excellent examination of what happens when you attempt to change someone's gender who is not transsexual. For a transsexual, it in fact works the other way - often raised in the 'wrong gender role', and once we figure it out, we transition. Gender is not the same as physiological sex - or even chromosomal sex. However, as as the tragic case of Mr. Reimer points out, gender is not entirely a construct of socialization either.
Having walked the path of transition as an adult, it is neither easy, nor done 'on a whim'. I would not wish the distress I have lived with prior to transition upon anyone.
MgS: Thanks for stopping by. There is no question that this is a serious issue. And no one takes it lightly. But you admitted that we don't know the long term effects of this or its safetly. That makes this unethical human experimentation in my view, and moreover, on children who don't have the capacity or ability to decide for themselves.
I also worry, as the editorial pointed out, that a lot of his emphasis might push children onto difficult paths they might not otherwise have taken.
Wesley,
There is an interesting aspect to the transgender experience that cannot be underestimated, and does play into the ethical considerations involved.
A lot of transsexuals report that they knew something was awry from an excessively early age. (Often before any concrete understanding of gender would have formed psychologically)
So...in some respects, the question that Dr. Spack's work raises is whether allowing a child to transition prior to puberty will produce different results when compared to Dr. Green's study published in the 1980s. (Where a large percentage of GID diagnosed children ended up homosexual, and only a handful transitioned genders as adults)
I would point out that the WPATH SOC does address the ethical considerations around making such treatment available:
Adolescents may be eligible for puberty-delaying hormones as
soon as pubertal changes have begun. In order for the adolescent and his or her parents to make
an informed decision about pubertal delay, it is recommended that the adolescent experience the
onset of puberty in his or her biologic sex, at least to Tanner Stage Two. If for clinical reasons it is thought to be in the patient’s interest to intervene earlier, this must be managed with pediatric endocrinological advice and more than one psychiatric opinion.
Two goals justify this intervention: a) to gain time to further explore the gender identity and
other developmental issues in psychotherapy; and b) to make passing easier if the adolescent
continues to pursue sex and gender change. In order to provide puberty delaying hormones to an
adolescent, the following criteria must be met:
1. throughout childhood the adolescent has demonstrated an intense pattern of cross-sex and
cross-gender identity and aversion to expected gender role behaviors;
2. sex and gender discomfort has significantly increased with the onset of puberty;
3. the family consents and participates in the therapy.
In any event, the genie is out of the bottle, and there are already some people on this path. In some respects, only time will tell what the long term outcomes will be.
The thing that bothers me about this is the age of the children involved. A lot of girls and boys go through issues related to what society expects of them as girls and boys. For instance, some girls love to play with dolls, play dress up, and have tea parties with their friends. Other girls want nothing to do with all of that and love playing in the mud, assembling toy race cars, and generally having a "take charge" attitude that is normally expected of boys. I've heard these characteristics mentioned as signs that a girl is actually a boy inside, and I see that as an imposition of gender roles on a child's developing personality. Boys who tend to be more gentle and sensitive, who like music and other things associated with feminity, are also teased and looked upon as feminine, which could lead to some gender confusion in that context.
Moreover, I am a bit concerned that we tend to eroticize love in this culture to such an extent that other legitimate forms of love-such as friendship-are ignored. When such drastic interference starts so young, I worry that boys and girls who have close friendships with one another will be regarded as having LGBT tendencies because people have forgotten about friendship's former status as a form of love.
On the other hand, I certainly empahtize with the significant problems children encounter in their latter teens when they hit puberty and any feelings of gender confusion they may have had as children become a part of their identity to the extent that they identify as the opposite gender inside. In such cases, I would argue that parents allow such children to dress and act like the desired gender and see if they actually feel comfortable in that role. Then, when the person is older, like 18-21, he or she can make a mature decision about whether or not to have a sex change. That way children aren't being experimented on with dangerous drugs or prematurely put into roles that were a reflection of the confusion many young people go through in puberty.
T. E. Fine, writing off the cuff here, but I know of the young man you speak of. He was Canadian, and there was a fad in Canada in the 1970s and before (as here in the US) for harmful experiments and family interventions.
The young man received a legal settlement years later, IIRC, but he recently committed suicide. After all those years as an experiment, he remained fundamentally unhappy, with tragic results.
I remember that case. I really do think it's better to leave nature alone, and if someone, as an adult, wants to take steps, and allow themselves to be a guinea pig, let them do it without others butting in on the decision. I think that nature probably has been creating this situation in humans from time to time for millenia; the myth of Iphis and Ianthe, who was in other myths simply a river nymph, may refer to it; I don't mean to downplay the anguish it causes, but it seems to me that the young person has enough on their plate when this is his or situation without others interfering. It does seem that science being willing to "help" and to do transgender surgery, etc. came along at the same time that the issues of abortion, euthanasia, and assisted suicide became prominent, and they all have to do with the individual wanting what they want, wanting to avoid what they don't want, wanting control over their own bodies, and wanting medicine to provide an answer that messes with nature, with procedures involved being referred to as having the intention of "helping." Maybe transgender people are happier after the switch, but the ramificaitons for the rest of society are less positive. At least it hasn't been like euthanasia and assisted suicide in terms of the denouement in society being something being foisted on people who haven't chosen it -- until now. These "wonders" and "freedoms" we have seem to end up disrespecting boundaries.
There is a distinct difference between a GID child and John Reimer's case. In Reimer's case, someone attempted to remediate a serious medical error (a circumcision went badly wrong), and imposed an identity on the child. This is quite different from the criteria that would describe a cross-gender child's condition.
Reimer's case is only tangentially relevant to transsexualism as a condition.
Maybe transgender people are happier after the switch, but the ramificaitons for the rest of society are less positive.
How is it "less positive" for society? You have (in general) a happier, healthier and more productive member of society. I'm having a hard time seeing a downside here.
BTW - we aren't talking about surgery for adolescents here - those decisions wait until later...the issue here is drugs that will postpone puberty.
Absolutely the Reimer case and GID are distinct in terms of the origin of the situation; they are similar only in that doctors imposed alterations on a child, in the former via first circumcision, and then the stunt they pulled, in the latter in terms of the child being a child.
I have met post-transsexual persons who seem happy to have made the change. I'm not saying that it's not positive for them. I'm saying that society doesn't seem to be able to make distinctions and restrain itself re the directions in which it moves once the means for one group to tamper with nature are available.
p.s. Nor am I saying that transsexuals started the trend we have now, just that medicine and science being able to do stuff is coinciding with their, and people's, wanting to do, and doing, all kinds of stuff, not all of which is positive.
I was born in 1960. I remember a boy who, starting in elementary school, always wanted to spend recess on the girls' side of the playground. Remember, this is at an age when most boys think girls are icky (and the girls heartily return the sentiment.) He brought his Barbies to school and wanted to play dolls with us. At that time, in a small town in Mississippi, that was a BIG DEAL. I'm sad to say that we shunned him. The boys did too, not that he probably cared. (In science fiction this is called "Seek out the mutant [and destroy it]".) I'm sure he was miserable. I suppose that nowadays he would have been considered transexual. It's hard to imagine anything well-meaning people of today might do that could be worse than what he actually went through, up to but not including the point of making physical changes in his body while he was too young to consider the ramifications.
Absolutely the Reimer case and GID are distinct in terms of the origin of the situation; they are similar only in that doctors imposed alterations on a child
There's little similarity at all when you recognize that in the Reimer case, the child had no say in the matter; in the case of childhood GID, the WPATH SOC (referenced in an earlier comment) are quite clear about the degree of caution recommended. Nobody looks at a child and says 'this child is trans' - the individual that is trans asserts it about themselves. (and yes, I do recognize that a child is seldom in a position to fully understand the consequences of decisions of this nature - which is one of the reasons I think the WPATH SOC expresses an appropriate level of caution)
I'm saying that society doesn't seem to be able to make distinctions and restrain itself re the directions in which it moves once the means for one group to tamper with nature are available.
Again, I must express a contrary opinion. The pressures on a transsexual NOT to transition are overwhelming. Availability of treatment is astonishingly sparse, and there are huge legal obstacles to be overcome post transition. (not to mention systemic discrimination)
The WPATH SOC also speaks to a social environment that is not at all at ease with transsexuals, urging an amazing degree of caution in the management of a transitioning individual's situation.
Society has regulated quite strictly against transsexualism, and continues to do so.
I think this wouldn't be half a terrible issue if it were only adults who suffered GID. Adults have fully formed brains and are able to reason through what they're thinking and feeling, and make appropriate choices concerning what they are and who they want to be. They can be worked with to get them on the correct path. I don't mean, to convince them they're wrong about wanting to change gender, I mean, to find out the best way to help them while doing the least amount of harm to them. I'm not crazy about sex change surgery because it can cause complications and possibly kill a body, and I would rather we limit the number of people who suffer and die, in equal measure.
But kids should NEVER have to deal with this slag. Every time adults come up with some great idea to "help" kids during trying times, it doesn't help. Kids need constant support and love and affection as they go through puberty to help them along, not suppressants for their natural hormones. I'm not discounting the kids' feelings, I'm saying there's too much potential for serious harm to the kids in question. Their bodies *have* to develop naturally first, or else they risk all kinds of problems - cancer, mental health issues, the list is endless, but one need only look up the medical information saved on the castrati of Italy to realize that kids aren't meant to be nutered, either medically or surgically, before they develop fully.
I found the draft guidelines here.
If one reviews the guidelines, they echo closely the cautious guidance of the WPATH SOC, and do reflect an appropriate degree of caution with respect to handling of adolescent GID patients.
For example:
1.1 We recommend that the diagnosis of gender identity disorder (GID) be made by a mental health professional. For children and adolescents the mental health professional should also have training in child and adolescent developmental psychopathology.
1.2 Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in prepubertal children with GID.
1.3 We recommend that physicians evaluate and ensure that applicants understand the reversible and irreversible effects of hormone suppression (e.g., GnRH analogue treatment) and cross-sex hormone treatment before they start hormone treatment.
1.4 We recommend that all transsexual individuals be informed and counseled regarding options for fertility prior to initiation of puberty suppression in adolescents and prior to treatment with sex hormones of the desired sex in both adolescents and adults.
This is not something which is going to be given out "willy nilly", as some of the popular media has portrayed it.
2.4. We suggest that pubertal development of the desired, opposite sex be initiated at about the age of 16 years, using a gradually increasing dose schedule of cross-sex steroids.
2.5. We recommend referring hormone-treated adolescents for surgery when 1) the real life experience has resulted in a satisfactory social role change, 2) the individual is satisfied about the hormonal effects, and 3) the individual desires definitive surgical changes
2.6 We suggest deferring surgery until the individual is at least 18 years old.
(and yes, there are transsexuals who transition in their teens - this is neither new, nor experimental - it's been going on for at least thirty years)
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