Current Protocols and Controversies in Child and Adolescent Gender Transitioning

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Many adolescents are adamant about their desire to undergo a partial or complete gender transition (De Vries, Cohen-Kettenis, & Delemarre-van de Waal, 2006a). In one recent survey of gender minority adolescents, 68% of the sample indicated that they had or were currently taking hormones (Grossman et al., 2006). Treatment protocols continue to emerge for gender transitioning in youth (e.g., the Gender Identity Research and Education Society’s guidelines on hormonal medication for adolescents, 2005). The most well-established guidelines were those crafted by the Harry Benjamin International Gender Dysphoria Association, or HBIGDA (now known as the World Professional Association for Transgender Health). This group of multidisciplinary professionals from around the world was formed in 1980. The WPATH established the Standards of Care (SOC) in order to provide minimal criteria for determining how and when to recommend interventions like hormone therapy and sex reassignment surgery to gender minorities. The current SOC (Meyer et al., 2001) contains guidelines specifically for the treatment of children and adolescents with GID.

The SOC for adult treatment are often referred to as a triadic therapy because these consist of hormone therapy, real-life experience, and sex reassignment surgery. Generally, all candidates for sex reassignment are required to have a written endorsement from mental health providers as a requirement for access to hormonal therapy and surgery. For those who are born biological male, an evaluation is required by an experienced therapist to verify the diagnosis of GID. Then they can begin taking feminizing hormones, which cause loss of muscle, redistribution of fatty tissue, and softening of the skin. The next step is the real-life experience in which the client begins living as a woman. If sex reassignment surgery is desired, the client must have two letters of documentation, one of which must be from a doctoral-level mental health specialist. Electrolysis and cosmetic procedures may follow.

In the case of a biological woman, a psychological evaluation is required before testosterone can be administered. Once testosterone is given, the patient typically experiences an increase in muscle mass, body and facial hair growth, voice lowering, and acne. Two separate recommendations are needed before a bilateral mastectomy can be performed. This usually occurs before the real-life experience. Penile constructive surgeries may be performed, although they are not regarded as fully successful (Seil, 2004).

The SOC (Meyer et al., 2001) for children and adolescents contain recommendations for two different forms of treatment interventions. The first category, termed psychological/social, refers to interventions that involve providing parents with support for managing the child’s gender expression. For example, practitioners might help parents identify areas that are most problematic in terms of the child’s gender nonconformity and “help the family establish some rules they can all live with about ways to act, dress, and behave at home and in public” (Fish & Harvey, 2005, p. 83).

The second category, physical intervention, includes three options. The first option is fully reversible interventions, including lutein hormone releasing hormone (LHRH) agonists. These hormones prevent the development of physical characteristics that have to be removed later. The second option is partially reversible interventions. The third is irreversible or surgical procedures. Adolescents may be eligible for partially reversible interventions at the age of 16. According to the SOC, surgical procedures are not to be employed until the age of 18, and this should include a real-life experience of at least two years.