So, someone by the name of Blaire White made a video about gender transition treatment for transgender children and adolescents. And I’m going to fact check it!

How puberty blockers work

“And of course, it begs the question of transgender children in real life. And I’m sure I chose a title for this video that lets you guys know up-front my feelings about children transitioning, but let me just say, I am against it, I am against it, I am against it. I have dealt with so many people trying to convince me that it’s a good decision to allow children to go on hormones or puberty blockers, and, you know, start their transition really, really early, and I’ve never been convinced.”

It’s important to be clear on the respective roles of puberty-blocking drugs and hormone therapy in the treatment of trans youth. Many of these kids have already been consistently presenting and living socially as their identified gender for years. When this treatment is indicated by thorough evaluation and proper diagnosis, puberty-blocking drugs – not sex hormones – are given to trans children near the onset of their initial puberty, usually starting around ages 10 to 12. These drugs reduce their testosterone or estrogen to very low levels, temporarily halting the physical changes of puberty due to hormones.

Trans children receive these injections or implants regularly for years in order to hold off these changes. This allows more time for them to be evaluated frequently by medical and psychological professionals and helps children be certain of whether they ultimately want to transition. If they choose not to transition, they can stop taking puberty blockers at any time, and their initial puberty will simply resume and continue normally. This is why the medical field, including the American Academy of Pediatrics (2015) and the American Psychiatric Association (Byne et al., 2012), classifies these blockers as fully reversible. These are safe medications that have been in use among both trans and cis children for decades now.

Again, puberty blockers are not hormones. They stop hormones. If, after this time on puberty blockers, a teenager does choose to transition, they can start taking estrogen or testosterone at age 16. These hormones do produce more permanent changes that are not necessarily reversible. While Blaire White describes this as “really, really early”, keep in mind that this treatment results in a puberty that occurs years later than it usually would, along with being subject to ongoing medical monitoring and control.

Who supports the use of puberty blockers?

“And listen, there are very few topics in this world that I feel like being transgender myself I have a bit more of an expertise on, but this is definitely one of them.”

There are others who also have expertise on this topic, such as major medical organizations and many hospitals. In addition to the American Academy of Pediatrics and the American Psychiatric Association, the proper use of puberty blockers for trans youth is also supported by:

(And me, being transgender myself.)

This treatment is available via clinics at major institutions, such as:

Johns Hopkins Children’s Center

Boston Children’s Hospital

Children’s Hospital Los Angeles

Columbia University Medical Center

Children’s Hospital of Philadelphia

Lurie Children’s Hospital of Chicago

Children’s National Medical Center

Hasbro Children’s Hospital

Not only is this a broad medical consensus, it’s a widespread and accepted practice affirmed by decades of clinical experience.

So:

“I am against it, I am against it, I am against it.”

The American Academy of Pediatrics is for it; the American Psychological Association is for it; Johns Hopkins is for it. Blaire White is against it. Why? Why do tens of thousands of physicians and specialists endorse and provide a treatment that’s not good enough for Blaire White?

Puberty blockers, hormone therapy, and fertility

“So here’s my first reason and honestly the biggest reason why I think that children should not be able to medically transition. Being on hormones sterilizes you. A lot of people don’t really seem to know that it sterilizes you, I think in part due to all the trashy tabloid headlines like every other week talking about ‘Transgender Man Gets Pregnant’. But it really does sterilize you. I’ve been on hormones for about a year and a half and I am completely, 100% sterile. I can never procreate. And if there’s anyone out there who thinks that a child, a minor, has enough foresight and the capability of deciding for themselves to sterilize themselves for the rest of their life, I don’t know, get your head checked.”

If an adolescent starts taking puberty blockers before they’ve reached a stage of maturity where sperm begins to be produced, and later goes on to start hormone therapy, then yes, they likely will not be able to reproduce using their own biological material. This is a known issue that’s been recognized by professionals in the field and identified as needing further exploration. For instance, at the WPATH symposium this year, one panel reviewed potential fertility issues facing trans youth, and noted that it is possible for children to delay taking puberty blockers in order to store gametes (Ehrensaft, Hastings, & Hsiao, 2016). Researchers are also investigating the feasibility of extracting and preserving gonadal tissue for future use in reproduction, an experimental process which has successfully resulted in live births (Amato, 2015).

Additionally, a clinical review by the LGBT Health and Development Program at Northwestern University noted that trans people who took blockers in adolescence and continue to take hormones in adulthood can discontinue those hormones until fertility becomes possible, although this is not certain for everyone (Kuper, 2014). The effect of hormone therapy on trans people’s fertility has been described in literature as “partially reversible” (De Roo, Tilleman, T’Sjoen, & De Sutter, 2016) – for instance, trans women may still be able to provide viable sperm (Scheim, Robinson, & Anderson, 2014):

For trans people already using hormones, a suspension of hormone treatment is recommended for a few months so that sperm production and quality can recover prior to banking. A study examining the effect of high doses of estrogen suggests that testes’ function can recover if the dosage is stopped. If interrupting hormone treatment is not an option, poor quality semen can still be frozen for later use…

Trans women and trans men on hormones who haven’t had surgery should not trust that sex will never result in pregnancy – it can. Medical literature makes note of this risk because it is real (Center of Excellence for Transgender Health, 2016). Trans men on testosterone who become intentionally or unintentionally pregnant are not just “tabloid headlines”. Thomas Beatie and the three children he gave birth to are not “tabloid headlines” (Obedin-Maliver & Makadon, 2016). This has actually happened a number of times (Light, Obedin-Maliver, Sevelius, & Kerns, 2014).

Telling trans people across the board that they are “completely, 100% sterile” and that they will “never” be able to reproduce is simply wrong – and more than that, it’s dangerous to trans people. It encourages them to delay or forego transitioning on the basis of a supposedly absolute outcome that actually consists of many different outcomes and options, and it discourages them from taking steps to prevent unwanted pregnancies. This is irresponsible.

Maturity and readiness for the physical changes of puberty

“So, another reason. Hormones change your body a lot, especially if you’re young. A lot of these are actually permanent changes. Like these, for instance [grabs breasts]. And I’m sorry, but the reality is, if that child ever decides to revert, or tries to go back, a lot of those things are going to be permanent.”

It’s true – hormones do change your body a great deal, particularly during puberty. But children who are not on puberty blockers will undergo those hormonal changes at a much earlier age, whether they’re ready for it or not. The onset and progression of their puberty will not be controlled, and it will not be subject to routine and detailed endocrinological and psychiatric monitoring.

So how are these hormonal changes of puberty supposed to be considered unacceptable in a tightly controlled and deliberately managed setting, but acceptable in a completely uncontrolled setting? If it’s bad for a 16-year-old girl to be able to decide to grow breasts after years of consideration and professional consultation, why is it good that an 11-year-old girl will grow breasts without any consideration and any consultation?

“You know, we seem to be on the right track with, you know, not letting children get tattoos and piercings, so why exactly would we let them dramatically alter their body’s physiology?”

Being a woman is not a tattoo. And this is not an accurate parallel.

Suppose that every child’s body simply began to tattoo itself automatically in certain patterns at puberty. Suppose you knew that for children properly diagnosed with a particular condition, there was a significant likelihood that they would find their emerging pattern of tattoos to be highly distressing throughout the rest of their life. There’s a concerning possibility that, as an adult, they will need extensive and scarring tattoo removals as well as the addition of the tattoos they wanted in the first place.

Suppose you had a treatment that would stop this child’s body from developing these tattoos for a few years, during which time they can consider and choose which set of tattoos they want, under the care and consultation of a team of professional tattoo experts. Eventually, they may choose to get the tattoos that they wanted to begin with, avoiding years of bodily discomfort and painful procedures in adulthood.

Why shouldn’t that option be available to these children? When you let their puberty happen without intervention, you’re already letting them get the very real and often permanent markings of adolescent development. Even if you cast your inaction as somehow ‘neutral’, the weight of the results is not diminished. An absence of action is not an absence of consequences.

(Explaining why something is wrong can take a very long time! Please continue to Part 2 for more.) ■

References

Adelson, S. L., & American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 51(9), 957–974.

Amato, P. (2015, March). Reproductive Options for Transgender Individuals. Paper presented at the meeting of the Endocrine Society, San Diego, CA.

American Academy of Family Physicians. (2014). Recommended Curriculum Guidelines for Family Medicine Residents: Lesbian, Gay, Bisexual, Trans Health. AAFP Curriculum Guidelines. Retrieved from http://www.aafp.org.

American Academy of Pediatrics. (2015). Gender Non-Conforming & Transgender Children. HealthyChildren.org. Retrieved from http://www.healthychildren.org.

American Psychological Association. (2015). Guidelines for Psychological Practice With Transgender and Gender Nonconforming People. American Psychologist, 70(9), 832–864.

Byne, W., Bradley, S., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . Tompkins, D. A. (2012). Report of the APA Task Force on Treatment of Gender Identity Disorder. American Journal of Psychiatry, 169(8), 1–35.

Center of Excellence for Transgender Health. (2016). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Fertility options for transgender persons. Department of Family and Community Medicine, University of California San Francisco. Retrieved from http://transhealth.ucsf.edu.

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., De Cuypere, G., Feldman, J., . . . Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.

De Roo, C., Tilleman, K., T’Sjoen, G., & De Sutter, P. (2016). Fertility options in transgender people. International Review of Psychiatry, 28(1), 112–119.

Ehrensaft, D., Hastings, J., & Hsiao, K. (2016, June). Fertility issues for youth: puberty blockers, hormones and decision-making through the lens of family building options. Paper presented at the meeting of the World Professional Association for Transgender Health, Amsterdam, the Netherlands.

Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W. J., Spack, N. P., . . . Montori, V. M. (2009). Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, 94(9), 3132–3154.

Kuper, L. E. (2014). Puberty Blocking Medications: Clinical Research Review. IMPACT LGBT Health and Development Program. Retrieved from http://www.impactprogram.org.

Light, A. D., Obedin-Maliver, J., Sevelius, J. M., & Kerns, J. L. (2014). Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstetrics & Gynecology, 124(6), 1120–1127.

Obedin-Maliver, J., & Makadon, H. J. (2016). Transgender men and pregnancy. Obstetric Medicine, 9(1), 4–8.

Scheim, A., Robinson, M, & Anderson, S. (2014). Fact Sheet: Reproductive Options for Trans People. Rainbow Health Ontario. Retrieved from http://www.lgbtqhealth.ca.

Wyckoff, A. S. (2016, September 29). Transgender children need support from families, doctors, schools: report. AAP News. Retrieved from http://www.aappublications.org.

Further reading

Full transcript: “Transgender Children? NO.” by Blaire White (October 5, 2016)