The Gender Conundrum

By Laura Fitzpatrick

It's a parent's nightmare dilemma: experts say there's a fifty-fifty chance your child will attempt suicide before age 20. Should you opt for an experimental medical treatment that might prevent it? Parents of children whom experts call gender variant are faced with just that question. If a child doesn't identify with his or her biological sex, the onset of puberty, says Laura Amato, a youth-suicide counselor who runs an online transgender support group, can make that child feel like "part of a real-life horror story ... because the wrong parts are changing."

No reliable data exist on how many U.S. children are gender variant, although the National Center for Transgender Equality estimates that as many as 3 million American adults are. But studies suggest that gender-variant adolescents are two to three times more likely to attempt suicide than other teens. Now, increasingly, hormone treatments that delay physical maturity are being seen as a lifesaving alternative for gender-variant kids, but the remedy is also generating medical and ethical questions about interfering with the natural development process. The treatment--a series of injections to interrupt the brain cascade that launches puberty by regulating gonadotropin-releasing hormone (GnRH)--has not yet been submitted for FDA approval for gender-variant children. But it is available from international physicians and some U.S. doctors prescribing off-label. In February the first U.S. clinic for gender-variant children opened at Children's Hospital Boston. Throughout the process of delaying puberty with hormone blockers, the clinic offers regular checkups with a gender specialist. Families that have opted for the shots are grateful. "We don't know what's going to happen next," admits an East Coast lawyer whose 13-year-old--born a girl and living as a boy--has been on blockers for three years under the care of a private doctor. "But we know that he's happy."

There isn't enough evidence yet to determine the long-term effects of artificially delayed puberty, but the FDA has noted no serious side effects in the nearly 20 years hormone blockers have been used in the U.S. to treat early-onset puberty in the short term. Although some U.S. studies show that interrupting puberty can weaken bone density, preliminary findings by the medical center of the Free University in Amsterdam, which has prescribed hormone blockers for about 80 children since 1987, don't suggest any such problems. The blocker treatment is also easily reversible: puberty begins as soon as drug use is discontinued. Otherwise, a child can stay on the blockers until about age 18, when he or she might be better able to deal with conflicting emotions or when hormones to aid transition to the opposite gender become a medically sanctioned option.

Still, there is evidence that hormone blockers can cause infertility. Cheryl Sisk, the head of neuroscience at Michigan State University, who studies the impact of pubertal hormones on neural development, adds that it's also too soon to know how delaying puberty plays into brain growth. Others worry about intervening with children before their gender identity is fully formed. Kenneth Zucker, a child psychologist at the Centre for Addiction and Mental Health in Toronto, notes that his studies indicate that comparatively few gender-variant children--about 12% of girls and 20% of boys--grow into transgender adults. "Gender development is a multifactorial process that evolves," he says. Nevertheless, Dr. Norman Spack, who spearheaded the Boston clinic and has assessed 50 children under age 21, says, "I've not had one change their mind."

Spack subjects his patients to a lengthy evaluation process before recommending hormone therapy. Kids undergo a battery of interview-based psychological tests to see if they meet the medically established criteria for gender-identity disorder. The clothing they wear, the way they style their hair and the type of toys they play with are assessed. Family members, teachers and primary-care doctors are consulted. After weighing all the evidence, an interdisciplinary team of doctors and psychologists determines the severity of the gender variation and whether to recommend the child for hormone blockers. But the final decision rests with the parents. To help inform families confronted with such choices in the future, the Boston team plans to begin clinical trials that will gauge the long-term effects of blocking the maturation hormones. "We don't claim to have all the answers," says Spack. "But right now, people are suffering because of those who won't ask the questions." There are many mysteries about the transgendered. This could clear up one of them.