Life's Surprising Complications

"The youth's voice is always paramount. Although the consensus in the medical community in the 1960s and 1970s was to view gender variance through a disease model in which associated behaviours, expression and declared identity were deemed pathological and in need of correction, the current approach is an affirming one that does not view gender variance as pathological."
"[Family doctors are urged to take a] thoughtful, affirming [approach and to avoid] influencing the adolescent to move down a path they would not have chosen for themselves."
"Some youth find that their dysphoria abates as puberty starts, making it important to allow initial pubertal changes to occur."
"[However, the drugs [hormone blockers] can also buy youth time] to explore their gender identity and expression without having to worry about ongoing  pubertal changes and development of secondary sexual characteristics that may be psychologically disturbing and undesired."
"Many youth understandably express the desire to go through puberty in their affirmed gender at similar ages to their peers, which would necessitate starting gender-affirming hormones at even younger ages."
Newly published article, Canadian Medical Association Journal

Born a boy, Danielle Sheridan, 8,  poses in her bedroom identifying as a female and choosing to live as a girl. Her peers and parents have been supportive. Rene Johnston, Toronto Star

"Drop the Barbie [approach] where it was deemed almost like you should 'correct' a child's behaviour or a child's identity."
"The opposite side of that is you don't even address gender at all -- the watch-and-wait approach. You avoid it and see what happens."
"The validating and affirming approach is an approach that gives you a bit of both of those, in the sense that you should address it, but maybe you shouldn't try to correct it either, but see where the youth is and where the parents are working together as a team, so that that youth is functioning well, both physically and mentally."
"I tell families that it allows you to take a deep breath, but a very long breath, so you have more time to figure stuff out and gather more information."
Dr. Joey Bonifacio, adolescent medicine specialist, St.Michael's Hospital, Toronto

"There are certainly youth who persist in their gender dysphoria. But it's also not uncommon to have youth who, a couple of weeks ago, decided that, after talking with a friend or researching on the Internet that maybe they're transgender."
"[Lacking a proper assessment], the risk is that teens may be started on irreversible medical interventions [cross-sex hormones] that really aren't appropriate, and they may later regret it."
Dr. Laura Edwards-Leeper, clinical psychologist, Boston Children's Hospital

Less than half of transgender youth feel comfortable discussing their health needs with their family doctors, a recent Canadian study concluded. Linked with the fact that wait lists at specialty gender clinics can be a year or even lengthier, the newly-published review gives family doctors advice on how they may support teens with 'gender dysphoria' -- what psychiatry labels the emotional upset that may come along with the incongruence between gender identified with and 'assigned' birth gender.

Recommendations on the use of hormone blockers meant to suppress puberty, along with 'cross-sex' hormones -- estrogens that develop a more feminine figure for trans girls and testosterone for trans boys to acquire a more angular jaw and masculine physique are summarized in the article. The review is seen as timely in the medical community in view of parents disagreeing between themselves over whether or not to credit a child's insistence that he/she has been recognized in the wrong gender to suit their emotional attachment.

"Social and peer contagion" resulting in "rapid-onset gender dysphoria" as the impetus pushing "cluster outbreaks" of gender dysphoria among friends created controversy when a recent study concluded with that hypothetical assessment. The study spoke to the theory that some teens (mostly trans boys, female to male) have been influenced by social media; YouTube transitioning videos in particular. The study was based on parental reports, and was swiftly attacked by advocates for the transgendered as methodologically impaired.

According to the authors of the CMAJ article, the sex ratio of teens presenting to transgender clinics seems to be alternating, "with many more youth who are assigned female gender at birth seeking care than those assigned male", with the reason behind the emergence of this new phenomenon, as yet unclear. Referrals to the gender clinic at B.C. Children's Hospital in British Columbia rose from seven in 2006, to 80 in 2017, as an example. And over 200 referrals are seen at the transgender clinic at Hospital for Sick Children in Toronto on an annual basis.

Studies from other countries beside Canada suggest that roughly one to four percent of teens identify to a different gender from that of their birth. According to the lead author of the new study, Dr. Bonifacio and his co-authors, hormone blockers should be given only when puberty starts -- at age 10-1/2 on average for children born female, and 11-1/2 for those 'assigned' to the male gender at birth. Hormones that normally increase during puberty are blocked by these drugs.

The international medical organization, The Endocrine Society's position is that cross-sex or 'gender-affirming' hormones may be administered around the age of sixteen, or as young as 13-and-a-half in particular circumstances. On the other hand, Dr. Edwards-Leeper who assisted in the creation of the first hospital-based clinic in the U.S. for transgender youth, is concerned that lacking proper assessments by trained mental health experts, family doctors might be too amenable to prescribing cross-sex hormones whose affects are irreversible.

Though puberty blockers can be life-savers for many transgender youth, estrogen for male-to-female transitioning causes breast development and testosterone for female-to-male can cause a permanent deepening of the voice. A too-hasty decision with respect to a child's future gender based on insufficient evidence that transition should proceed could mark that person for life in a manner that considerably complicates a delicate issue, rather than solving it.

Guidelines to be published Monday recommend doctors take an unconditional “affirming” approach, that drugs to stop puberty may begin as early as age 10-and-a-half and that “cross-sex” hormones — estrogens so that a trans girl develops a more rounded figure and testosterone to give trans boys a more angular jaw and masculine physique — may be administered at age 16. Getty Images