Pausing puberty with hormone blockers may help transgender kids

Crumpled colorful paper notes with gender symbols.

Transgender adults start as transgender children, and doctors are now poised to help these children cope with their perceived gender identity before they enter the "wrong" puberty, by postponing puberty's onset.

The term "transgender" refers to people who feel that their gender identity, which is possibly wired into the brain, differs from the gender determined at their birth, which usually is based on genitalia. Gender identity is independent of sexual orientation.

Once puberty hits for transgender children, their bodies produce changes that their brain may not want. For example, children who identify as male may begin to develop breasts, or those who identify as female may start growing facial hair. Gender identity might not have caused concern for children still in the prepubescent state.

But confusion and depression often follow puberty's onset. Studies show that more than half of transgender youth have attempted suicide at least once before their 20th birthday.

Last December, the suicide of 17-year-old Leelah Alcorn, who was assigned a male gender at birth but who identified as female, ignited a national discussion; her social media postings and suicide note pointed to her initial elation at age 14 of her self-discovery that she was transgender, only to be followed by her parents' denial and rejection.

Although each transgender child's development is unique, one medical intervention that can help with the transition to adulthood is a hormone therapy that postpones puberty. Drugs that block hormones, called GnRH agonists, are endorsed as standard care for transgender youth by the Endocrine Society, the nation's largest professional medical organization devoted to endocrinology and metabolism.

"With hormone blockers — drugs that have safely been used in other contexts for a very long time — we can hit the 'pause' button on puberty," said Dr. Johanna Olson, director of the Center for Transyouth Health and Development at Children's Hospital Los Angeles.

Olson said that this pause, which is reversible, can offer many advantages. From the child's perspective, a pause can allow for a better timing of a gender-appropriate puberty. For example, a transgender kid born with ovaries who is about to enter into a female puberty at age 9 wouldn't want to start testosterone therapy at that age to transition to a male because he would then be entering puberty many years before his male peers.

"We want people to go through their puberty process with their peers," Olson said, adding that puberty is a trying experience to begin with, and concordance makes the process easier. [10 Facts Every Parent Should Know About Their Teen's Brain]

Similarly, if someone born with male genitalia were to start estrogen therapy before puberty, it could stifle the growth spurt that boys undergo during this time, thus resulting in stunted height for the transgender youth who identify as female. Our society puts value on height for both males and females, Olson noted.

For the parents of transgender children, the several-year hiatus from their child's puberty can give them time to understand what their child is going through and to determine, with the help of professionals, if their child is truly transgender.

Then, should the child wish to transition more physically into his or her self-identified gender, the parents would have more time to consider the social ramifications, such as finding a welcoming environment for the child at school or in the community.

The hormone-blocker therapy is part of what researchers call the Dutch model, as it is based on a landmark study published in 2006 on 54 transgender young people in the Netherlands. That study helped to establish the medical safety of the therapy.

Doctors published a long-awaited follow-up to this study in the October 2014 issue of the journal Pediatrics, and found that the mental and physical health of these children were similar to or better than that of same-age youths from the general population.

Editors of the journal Nature Reviews Urology wrote in November 2014 that "the 'Dutch model' of care should help to silence critics and reassure the growing number of clinicians treating [the transgender youth] population."

One outspoken critic of the use of hormone blockers has been Dr. Paul McHugh, a retired psychiatrist at The Johns Hopkins Hospital and a former adviser to President George W. Bush. In a 2014 opinion piece in the Wall Street Journal, McHugh described the transgender experience as a mental disorder — a view not shared by mainstream doctors.

Olson said she has been inspired by the Dutch study but noted that this study examined a homogenous group of youths, mostly Caucasian and living in a society generally more open to gender diversity than that of the United States. She said she hopes to complement this work with a study on a more diverse population.

Olson described her office filing cabinet as containing "probably the only multiethnic transyouth data that exists in the world." She has been following 101 individuals on cross-sex hormones for four years and recently enrolled 15 kids in a hormone-blocker study.

One of Olson's patients in the hormone-blocker study, now named Ryan, was assigned a female gender at birth. Ryan was a "tomboy" growing up, and one day last year while he and his mother were driving in a car, he blurted out, "Mom, I don't feel like a girl inside," his mother Sharon told Live Science. (The family asked that Live Science withhold their last name to protect their privacy.)

Sharon said she was open to Ryan's concerns and wasn't exactly surprised by his announcement, because his desire to be a boy before this point was apparent in everything "down to his underwear choice," she said. She took him to see a counselor, who confirmed that Ryan was transgender.

"The biggest blessing" was understanding what Ryan was going through, Sharon said. "I wish we had known at a younger age what this was called."

Nevertheless, Ryan, now age 12, appears to be well accepted as a boy in his school and community, Sharon said.

But such a positive gender transition in terms of self, family and community acceptance is not yet common, Olson said. Alcorn concluded her suicide note with the words "Fix society, please," in reference to the years of isolation and rejection she suffered as a transgender youth.

Science might help with societal acceptance. Numerous studies suggest that brain structure, more so than genitalia, determines gender identity; a transgender individual who perceives he is male has a brain structure that indeed corresponds with a male brain, studies indicate, and likewise for those who perceive themselves as female. That is, gender identity isn't a choice.

More transgender faces in the public might help, too, Olson said. Bruce Jenner, the winner of the 1976 Olympic gold medal in the decathlon, announced publicly last month that he is transitioning to a life as a woman.

Jenner's announcement, and the national discussions that have followed, will help the public understand that transgender is a biological reality and part of the normal spectrum of human gender experience, Olson said.