Starting with T

The Baby Game

(The Gender Centre advise that this article may not be current and as such certain content, including but not limited to persons, contact details and dates may not apply. Where legal authority or medical related matters are cited, responsibility lies with the reader to obtain the most current relevant legal authority and/or medical publication.)

 

How to Make Babies in a Transgender Relationship

by Maggie Smith, R.N.
Article appeared in Polare magazine: July 2010

The process of storing samples is done by freezing or cryopreservation.

With technology as it stands at present it is certainly possible for a person to bank semen, eggs or embryos for future use

As society and governments slowly change their attitudes toward same-sex and transgender relationships, and laws are changed to reflect these attitudes, it is to be hoped that more transgender people will fulfil the role of parent. I certainly hope the view that "losing the right to reproduce is the price one pays to transition" will disappear and that medical professionals will start to have conversations about future parenting with transgender people prior to transition.

Transgender people wishing to transition usually start on hormone therapy as part of the transition process. Many personal, social and medical issues may arise during transition and the last thing a person may ponder is their desire for offspring, now or in the future. With technology as it stands at present it is certainly possible for a person to bank semen, eggs or embryos for future use. The collection of these is best done before commencing hormone therapy.

In this article I will discuss the different methods for obtaining and storing eggs or semen/sperm and ways in which these may be used for assisted reproduction. I am not an expert on assisted reproduction and strongly urge those interested to discuss it with their doctors or health care professionals.

Sperm Banking / Semen Cryopreservation for Transgender Women (Male to Female)

The collection and storage or "banking" of sperm has been available since the 1950s. To date semen/sperm samples have been stored for over twenty years and successfully used. The process of storing samples is done by freezing or cryopreservation. Therefore the storage of sperm is called semen cryopreservation, but it is more commonly known as sperm banking. Semen is the name given to the ejaculate from the penis. Sperm is only part of this fluid. The terms "semen" and "sperm" are often interchanged even though this is not correct usage. In this article I will use the term "sperm" to mean either semen or sperm, as this is the term most commonly used in informational literature.

The feminising hormones taken as part of transition for M.T.F.s decrease sperm production (hypospermatogenesis), and can ultimately lead to no sperm being produced (Azoospermia). Stopping feminising hormones can allow sperm to be produced again, but the amount of time the hormones have been taken may affect the amount of sperm and/or quality of sperm produced. It is possible, if a person has not been producing sperm for a long time that this may be irreversible. The amount of time it takes for a person's sperm production to return or the long-term effects of feminising hormones on sperm production is not known. Obviously if gender reassignment surgery has occurred and the testes have been removed this creates a permanent state of sterility.

If a transgender woman wishes to have a baby and has a female partner, the first option would be to stop taking feminising hormones and see if sperm production returns so that the female partner could be impregnated without assistance. This option may not appeal to some people as ceasing the hormones and the return of sperm production will also involve the return of other male physical characteristics. The collection and storage of sperm for future use may, therefore, be a more appealing option.

The sperm is stored frozen at private facilities set up for assisted reproduction or in vitro fertilisation (I.V.F.). Prior to donation a negative test result for H.I.V. may be required. A positive result of the H.I.V. test may not disqualify the donor from banking sperm, but it will be segregated from other donations. The sperm sample is usually produced by masturbation into a small sterile container. This is often done at the storage facility but there may be the option of bringing in the sample. As a rule the sooner the sample is frozen the better the survival rate of the sperm.

Another option for obtaining the sperm sample is testicular sperm aspiration or extraction. The technique used for testicular aspiration is quite simple and relatively free from complications. The procedure requires a local anaesthetic. A small needle is inserted just below the surface of the testis and a small piece of testis immature sperm is then extracted.

This technique is normally used for I.V.F. rather than sperm donation alone, as the sperm removed may not be fully functional, but this is an option to be discussed with the fertility service.

Once collected by whatever method the sample is frozen. There is a cost for the storage of the sperm and the storage facility needs to be kept up to date with any address changes etc.

Lack of payment of storage fees or not being kept up to date with current contact details could result in the sample being disposed of.

When the sperm is required for use it is thawed out. If the transgender woman has a female partner there are a couple of options available to the couple to bring about conception. The sperm can be introduced into the female partner via artificial insemination. This basically involves inserting the sperm sample into the vagina or near the cervix, using a gentle plastic tube or a syringe without a needle. Conception is dependent on a number of factors as with non-assisted insemination. It would be best to ensure the female partner is ovulating at the time (producing an egg), and the ability of the sperm to make it to the egg and penetrate it. The success rate for conception varies greatly but can be from ten to twenty percent success rate per attempt.

Another way that conception can occur is through in vitro fertilisation (I.V.F.). I.V.F. is a process by which egg cells are fertilised by sperm outside the womb. For this, egg samples will need to be collected from the female partner. This is through the same process used for any I.V.F., which I will discuss later in the section on egg collection and donation.

With the semen sample the sperm is separated from the semen and placed in a Petri dish around the egg. The sperm then fertilise the egg by penetrating it, or the sperm can be injected into the egg (a process called intracytoplasmic sperm injection). The fertilised egg is then observed to ensure it is viable (going to produce a foetus). The egg is then inserted into the female partner's womb for three to five days. Success rates vary from ten to fifty percent per cycle, or attempt. As with any attempts at becoming pregnant this can take a number of cycles or attempts. (At the end of article I will list possible costs for the different procedures discussed.)

For a transgender woman (male-to-female) with a male partner the options are far more limited in Australia. They would need to follow the procedures adopted by male same-sex couples in Australia. They would need to find an egg donor and a surrogate mother to carry the child. They could use stored sperm for this.

New South Wales has no current legislation regarding surrogacy and it is therefore not specifically prohibited but operates under the National Health and Medical Research Council ethical guidelines.

The N.S.W. Law Reform Commission Report (1988) recommended commercial surrogacy be "prohibited by law and non-commercial surrogacy not be encouraged". As in all States of Australia, when surrogacy arrangements are made, the birth parents are lawfully deemed to be the legal parents. This may bring up some difficult legal situations.

Egg Banking / Oocyte Cryopreservation for Transgender Men

There are a number of options available to a transgender man. The collection of unfertilised eggs (oocytes) is much newer technology. The freezing of embryos has been used successfully for decades. Again, these options would be best thought of before commencing masculinising hormone therapy.

The taking of male hormones decreases egg production from the ovaries and will lead to cessation of egg production and amenorrhoea (no periods). This is, however, considered a reversible situation.

How long it will take for ovulation and periods to return if hormones are stopped is, however, an individual response and will also depend on how long a person has been on the hormones. If the ovaries have been removed as part of gender reassignment, this creates a permanent state of infertility.

The first possible option is, if the ovaries are still intact and a transgender man wishes to conceive and carry the baby (depending on his age, fitness and any other normal considerations for pregnancy), the first thing to attempt could be to stop taking hormones and see how long it takes for periods to return.

If the transgender man has a male partner it would then be a matter of sexual intercourse or artificial insemination and, it is to be hoped, conception.

If the transgender man has a female partner but wants to carry the baby the couple need to find a sperm donor. Then fertilisation could occur by whatever method the parties agree upon (assisted fertilisation at home or at a clinic).

If it is decided that a person wants to bank eggs for future use then the person will require the help of a fertility and reproductive assistance service, e.g. I.V.F. service.

For either of the two processes I am about to discuss, the transgender man's eggs will need to be collected and stored.

The process of collecting or "harvesting" eggs normally involves the person going on a course of hormones or fertility drugs to stimulate egg production. Normally a person produces only one egg a month from one ovary. The aim of giving hormones is to have multiple eggs produced at the same time.

These fertility drugs may be given as a nasal spray, tablets or by injection. The drugs can affect a person and they do have side-effects. For the transgender man I should point out that the information I have found is for someone who has never been on masculinising hormones. I am unsure of the type of fertility drugs or the side-effects experienced if a person has been on masculinising hormones.

Blood hormone levels will be monitored to detect when the eggs are mature. An ultrasound scan confirms that the eggs are ready to be retrieved. Shortly thereafter the patient will be sedated and the doctor will remove the eggs from the ovaries using a fine, hollow, needle. Another ultrasound helps the doctor to locate the eggs.

The eggs can then be frozen (Oocyte cryopreservation) for future use, or used as a fertilised egg for embryo freezing. To fertilise the eggs there would need to be a sperm donor.

For the transgender man with a female partner there is also the option for the partner to carry the baby. This option may appeal to some. In the case where the embryos have been frozen and stored earlier it means the transgender man does not need to cease masculinising hormones or go through the pregnancy. Be aware, however, that in Australia the person who carries and births the baby is the legal parent.

I.V.F. has been successfully used since the late 1970s. This originally involved the fertilisation of the egg outside the body, the egg being kept incubated for several days until it was deemed the egg was successfully fertilised, then the embryo was replanted in the woman.

The ability to freeze embryos successfully and use them at a later date has also been used for decades. Embryos have been successfully used after being frozen for up to ten years. At present five to ten years storage time is considered safe for a viable embryo to be used. For embryo freezing from a known donor it is advisable to have a clear understanding of the future use of these embryos.

The process of freezing an unfertilised egg is much newer technology with the first successful use of a frozen egg used for I.V.F. in 1986. The success rates remained quite low until the past few years when the freezing technology was improved. Due to this relatively new change in the technique of freezing eggs it is difficult to say how long eggs can be successfully stored. Potentially up to a decade but at this stage it cannot be stated with confidence.

Success rates for either type of freezing and implantation are anywhere from ten to fifty percent. This is dependent on many factors and is an averaged figure. For example, one person's cycle of I.V.F. may have 100 percent success then the next may have none.

Cost of Cryopreservation and/or I.V.F.

The costs of services given below are only an approximate guide. Each facility will charge different fees. The prices given are also pre-Medicare rebate (where possible), and private health insurance fund rebate.

Medicare and private health insurance funds will need to be checked by the individual or couple before commencing the processes.

Costs may also vary depending on the number of attempts at I.V.F. or other services are required. Nor have the costs of an anaesthetist, where required, been taken into account.

Costs for I.V.F. and Cryopreservation Processes

Sperm banking: The cost for storage of sperm varies depending on the facility but as a rule will be anywhere from $300 to $400 per year.

Sperm aspiration: Approximate cost $1000 - $1500 plus storage or banking costs if stored.

I.V.F. costs: I.V.F. including egg stimulation, collection and insertion can cost from $15,000 to $20,000. Total expense will depend on the type of procedure required and the number of attempts.

Egg banking or embryo storage: $300 to $500 a year.

As I wrote this article it became more and more complex, trying to cover all situations. As we know, gender is not the same as sexuality so there are many different possible fertility situations to consider. I apologise if I have left any couples or combinations out. I have not touched on people's moral or religious stances on embryo freezing nor the legalities associated with using sperm donors. These all need to be investigated or thought about before commencing procedures.

I do hope, however, that this encourages a few people to think about their right and ability to have children so that they may have these conversations with their health care provider.

The information in this article does not represent the views of Polare or the Gender Centre, the article is intended only as advice. Any questions or concerns should be directed to your health care provider.

Note: Medicare does provide a rebate for some I.V.F. procedures at a rate of 75 percent of the scheduled fee for inpatient procedures and 85 percent of the scheduled fee for outpatient. To check what procedures attract a rebate and the scheduled fee for each procedure, visit go to the Department of Health and Aging External Link website and enter search terms such as "assisted reproductive technology" or I.V.F.

Maggie Smith R.N.

Maggie was born in Brisbane and grew up on Stradbroke Island and moved to Sydney in 1996. She has been a nurse for over twenty years and is currently working as a clinical nurse specialist in sexual health and H.I.V. services. Through this role she was introduced to the transgender community and the specific, specialised and often under-resourced area of health care and education. She is committed to improving access, knowledge and skills in health care to the transgender community especially within sexual health and is especially passionate about raising awareness within the medical and nursing field of the need for improved health services to the transgender community. As a member of the Gender Centre's Management Committee for several years, she has assisted the Manager and staff in developing health services through her knowledge of the health care system.

Polare Magazine is published quarterly in Australia by The Gender Centre Inc. which is funded by the Department of Family & Community Services under the S.A.A.P. program and supported by the N.S.W.Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion and debate on gender issues. Unsolicited contributions are welcome, the editor reserves the right to edit such contributions without notification. Any submission which appears in Polare may be published on our internet site. Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc., the Department of Family & Community Services or the N.S.W. Department of Health.

The Transitional Male

The Young M.T.F. Transsexual

(The Gender Centre advise that this article may not be current and as such certain content, including but not limited to persons, contact details and dates may not apply. Where legal authority or medical related matters are cited, responsibility lies with the reader to obtain the most current relevant legal authority and/or medical publication.)

Rapid and Successful Assimilation into Society as Females

by Annie Richards, Second Type Woman 
Article appeared in Polare magazine: January 2010 Last Update: October 2013 Last Reviewed: September 2015

German teenager Kim Petras became world famous as the youngest person ever to have had S.R.S. - age sixteen, although that claim is almost certainly incorrect, her exuberant femininity has made her an icon for young transsexuals.

All the current evidence indicates that the under eighteen trans girl will identify totally with her new female gender and appearance, passing well both psychologically, socially and physically; and be far more happy as a female and have no regrets.

This article discusses the treatment of transsexual boy-to-girl children. When allowed to, such children are almost always able to rapidly and successfully assimilate themselves into society as females. This alone is enough to differentiate them from transsexual women who transition when adult.

It is necessary to distinguish between intersexed infants, who in some cases are assigned a gender contrary to their genetic sex, and gender identity dysphoric (G.I.D., a.k.a. transsexual) children. While very young intersexed infants have no say in their sex assignment or reassignment (which is usually done before they are twenty-four months old), transsexual children consciously reject the gender in which they are being brought up at some point between two years-old and puberty.

Since the 1960's - when Dr. John Money, a physician at Johns Hopkins University, made the medical community at least recognise transsexuality - there has been an ever increasing incidence of male-to-female (M.T.F.) reported G.I.D. cases and requests for treatment across all age groups. However in recent years the growth in reported cases among teenagers, particularly boys, has been extraordinary. No one compiles official statistics on transgender youths, but everyone agrees that their numbers are rising very quickly. Undoubtedly this is partly the result of increased access to information. A child today with "gender dysphoria" - the catch-all term for disconnect between body and gender-identity, will almost certainly have heard about transsexuals by the time they reach the critical point of puberty. Many children with G.I.D. problems learn about transsexualism from television shows and documentaries and then go online, looking up anything and everything they can find out about transsexuality, and start to chat and email with other transsexuals.

With the increasing awareness and more favourable publicity given to transsexualism, M.T.F. children who in the past would have suppressed their female gender, or at least deferred dealing with it openly until reaching adulthood, are now coming forward while still children. In most cases their families respond positively and supportively, but occasions of outraged parents and internal family battles about how to deal with a would-be daughter will never cease completely.

Unfortunately there continues to be a reluctance in the medical profession to pro-actively treat gender-identity disordered children, even when they are diagnosed as "core" or "true" transsexuals. However even the famous/notorious Standards of Care for Gender Identity Disorders (which very few medical professionals dare to defy) has now advanced slightly as regards young transsexuals as it reached it's sixth edition in 2001.

While recent trends are somewhat encouraging, young transsexuals (under twenty) seeking and obtaining medical help and treatment are still vastly outnumbered (10 or 20 to 1?) by their older counterparts - most of whom bitterly regret their years of delay. Also, young trans girls tend to immediately go stealth after transition, and the girls referred to in this article are exceptionally brave about their transsexuality - or had little choice as they were outed by the media.

Sex Assignment

A person's sex can be determined or judged by many factors, including:

  1. Legal Sex: In the U.K. the infamous ruling by Justice Ormrod, determined that this was the sex stated on the original birth certificate - although since 2004 the Gender Recognition Bill has overturned many aspects of this ruling;
  2. Hormonal Sex: Based largely upon male testosterone plasma levels, or female oestrogen and progesterone plasma levels;
  3. Chromosomal Sex: Male "XY" or female "XX" genes as determined by a karyotype study (there are many other combinations);
  4. Internal Sexual and Accessory Organs: The presence of male (testes) or female (ovaries) gonads, and male (e.g. vas deferens, ejaculatory ducts and prostate gland) or female (e.g. uterus, vagina, fallopian tubes) accessory organs;
  5. External Sexual Characteristics: Male (e.g. penis, scrotum) or female (e.g. clitoris, labia majora) appearing external genitalia, and other male (e.g. beard) or female (e.g. breasts) appearing secondary sexual characteristics;
  6. Gender Role: The sexual role a person lives in, and the sex they are perceived as being. It has been defined as "A social status usually based on the convincing performance of femininity or masculinity"; and
  7. Gender Identity: The gender a person identifies with and believes they are.

Factors 6 and 7 are commonly and unfortunately combined under the term "gender-role", but I prefer to keep them separate when possible. A particularly confusing but frequent use of the word "gender" is in the phrase "gender reassignment surgery (G.R.S.)". It's essential to differentiate between a person's physiological sex (factors 4 and 5), and a person's social and mental gender (factors 6 and 7). Surgery can't ever change the latter and the phrase "sex reassignment surgery (S.R.S.)" is a better, although still seriously exaggerating, description of what surgery can achieve.

Gender

For most children their legal, chromosomal and physical sex agree with their mental gender and preferred gender role ..., but not always. As already mentioned, children with gender-identity problems are described as having gender dysphoria.

Establishing a gender-identity is a process that most people take for granted, but that no one completely understands.

Scientists and sociologists agree that traditional gender roles are in many ways socially constructed, e.g. girls learn to wear dresses and boys learn to wear trousers. But no one seems to understand what makes a transsexual child raised in a male gender role embrace the female role as her own and vice versa. Nor can anyone explain why many intersexed children raised as one sex eventually migrate back to the gender that their genetics or their prenatal hormonal environment would have predicted.

Bill Summers, a professor of medical history at Yale who studied the science behind gender and sexuality says "You have to learn somehow what it means to be a boy or a girl. You don't come born with the idea. But enough people say, "I always knew I was a boy but I was raised as a girl" that I can't doubt they have these feelings."

Summers points to the work of Dr. John Money who became famous in the 1960s for recommending and surgically facilitating the transition of a young boy [an identical twin] with a botched circumcision into living as a girl - the so called "John/Joan" case. Money initially declared the gender re-assignment to be a success, but his work was later undermined when the girl grew up with a masculine gender-identity anyway. Summers notes that "the whole idea [was] that given hormone treatment and the right social environment, you can determine gender-identity. It's not really quite so simple."

The bottom line seems to be that sociologists and psychologists still don't know where gender-identity comes from or why - but it is unlikely that either biology or society operates totally independently from the other. The only current certainty seems to be that when young children decide that they are a boy or a girl and this decision contradicts their supposed physiological sex, the result is much anguish and cost to the child, the parents and the medical profession.

Young boy-to-girl transsexuals have few doubts about their sex - they know that they are really female and unlike older transsexuals can usually easily pass as such.

Maité Schneider started hormones age 18, but has not yet had surgery. (Brazil)

Sexual Identification of Transsexual Children

It is important to note that many boy-to-girl "transsexuals" do not consider themselves to be transsexual - indeed they often actively dislike being called such - they just consider themselves to be girls. The reality is that young trans girls often associate the word "transsexual" with television documentaries featuring strange balding middle-aged men, married, with children, who at the end of the program still look, sound and behave like men wearing wigs, dresses and too much make-up to their very discriminating eyes and standards. Young trans girls simply cannot relate themselves with these examples of transsexuality - their problems are totally different, and passing is rarely one of them.

A key, if obvious, differentiator between transsexuality emerging in children and the far more numerous instances of it emerging in an adult is the pre-puberty age at which noticeable cross-gender behaviour appears in the former group. According to one study, two thirds of transsexual boys are aware that they belong to the opposite sex and exhibit such behaviour" by age five, and 77 percent by age ten. Another study of 137 M.T.F. transsexuals confirms these figures, finding 70 percent exhibited cross-gender behaviour before age ten, and another 20 percent before age fifteen.

For example Richard ("Richie") always wanted to wear dresses like his sister, when age two and a half his mother caught him trying to cut his penis off with nail clippers, saying "this doesn't go here". At age seven he was finally diagnosed as having Gender Identity Disorder, his parents changed her name to Riley Elizabeth and let her go to school as a girl - where she blossomed from a "sad confused little boy into a happy young girl". The financial burden of Riley's medical care had been crippling, but her parents had no doubts - "seeing Riley's happy face now, it's worth every penny"

It seems that at least three-quarters of gender dysphoric children will eventually have sex re-assignment surgery (S.R.S.).

If clinical testing finds that the following conditions apply:

  1. onset of a desire to belong to the opposite sex before puberty;
  2. cross gender behaviour and social role without sexual arousal; and
  3. dislike for one's own secondary sexual characteristics.

... then core transsexuality, commonly known as "true" or "primary" transsexuality, is likely to be confirmed and appropriate sex-reassignment treatment should be started. However there still remains considerable reluctance by the medical profession to supportively treat a physically normal boy with gender-identity problems - a boy who's adamantly insistent that he's really a girl. The sex re-assignment of babies and very young boys became medically acceptable in the 1970s and 1980s (indeed, perhaps too common) - but has since become discredited and unfortunately there has been a carry over affecting young transsexuals. It seems to often require courageous and forceful parents before doctors will medically facilitate the transition of a minor.

Parents

An understandable reluctance to "come-out" to one's parents remains probably the greatest single obstacle to the early and successful treatment of many trans girls. On the other hand, things do seem to be improving, and television and the Internet are playing a key role in this - these days most transsexual children first learn about "transsexuality" from television programmes. Relating positively to this condition they - and often their parents - seek further information via the Internet and from books.

It is impossible to underestimate how important the understanding and support of parents is for a young transsexual's eventual success in life. It is also difficult to underestimate how much emotional strain having a transsexual child can impose on parents.

Many parents become a pillar of support and understanding, indeed there are many instances of parents going to extraordinary lengths and expense to aid their new daughter - for example moving house so she can go to a different school and avoid anyone who knew her as a boy.

In another positive example, Jamie never felt herself to be a boy, and when at age eleven she finally told her parents "You think that I am a boy, but I am a little girl!", they accepted her choice and she is now living very happily and confidently as their daughter.

On the other hand, there are also instances where the child tells the parents and the result is a nightmare of arguments and pressure. Rachel (formerly Daniel) describes how when she told her parents at age seventeen: "They didn't shout at me but the conversation was very heated. Mum got upset - although she said she'd guessed a while ago - and Dad was annoyed. They both said they didn't want me to dress up in the house and that I'd always be Daniel to them. ... My parents have been good to me, but they'll always see me as their son." Rachel is actually luckier than many girls. Enforced visits to a suitable psychiatrist (suitable for the parents at least) to treat the child's gender disorder are common. Perhaps in a few cases a "cure" is achieved, but more commonly the child suppresses his/her transsexuality, and if he/she persists then an eventual total rejection by one (usually the father) or even both parents may well occur. For example, Brazilian, Roberta Close, was disowned by her father, and only reconciled years later. While now a successful model and actress, for several years in her teens Roberta descended into the seedier side of life that all too many transsexual women go through in order to earn a living.

Often transsexual children feel unable to tell their parents about their feelings and needs. This usually means that a public admission of their transsexuality is deferred to adulthood - and the delay is always much regretted. But the resourcefulness of children should not be underestimated. For example, one text book (Man and Woman, Boy and Girl) describes how a woman secretly obtained and took hormones while still a young teenage boy. Her concerned parents eventually took her to a hospital for tests to help determine the cause of the resulting physical changes, but she had had enough warning to stop and let her system clear. The doctors concluded that the changes were spontaneous and natural (some degree of gynaecomastia - male breast development - is quite normal in mid-puberty boys), and told the parents not to worry.

Medical Guidelines for the Treatment of Transsexual Children

The widely followed W.P.A.T.H. Standards of Care for Gender Identity Disorders, a document which has previously (and increasingly controversially) been against the hormonal treatment of under-sixteen year olds, has relaxed its rules slightly in the latest (2001) Version 6. It now states that:

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"Adolescents may be eligible for puberty-delaying hormones as soon as pubertal changes have begun. In order for the adolescent and his or her parents to make an informed decision about pubertal delay, it is recommended that the adolescent experience the onset of puberty in his or her biologic sex, at least to Tanner Stage Two." [on average this means about age eleven for biologic females, age twelve for biologic males) ...

"Adolescents may be eligible to begin masculinising or feminising hormone therapy as early as age sixteen, preferably with parental consent. In many countries sixteen year-olds are legal adults for medical decision making, and do not require parental consent." ...

"Any surgical intervention should not be carried out prior to adulthood, or prior to a real-life experience of at least two years in the gender role of the sex with which the adolescent identifies. The threshold of eighteen should be seen as an eligibility criterion and not an indication in itself for active intervention."

Although still not coming out in favour of starting feminising hormone treatment at a normal puberty age and delaying any sex-change surgery until at least age eighteen, the standards do at least now allow the treatment of very young adolescents with puberty-delaying hormones and thus help prevent the socially and mentally disastrous development of normal male [secondary] sexual characteristics and appearance in an under-sixteen M.T.F. girl.

In its defence, the Standards of Care are clearly and understandably concerned about some instances of unsuccessful boy-to-girl gender re-assignment of intersexed babies, such as the highly publicised failure of the gender re-assignment of David Reimer (a.k.a. the "John/Joan" case), and want to avoid any future repetition. If a boy is diagnosed as a transsexual then a failure to immediately start treatment is not only deferring the inevitable in the vast majority of cases, but is doing so at a considerable cost to the child's future as a girl and woman. It is indisputable that the earliest possible transition and pre-puberty hormonal and surgical treatment will offer most M.T.F.s massive psychological and physical benefits.

Early transition and commencement of treatment and transition will permit the transsexual boy-to-girl a female childhood, a normal puberty (excluding menstruation) and allow her to enjoy her teenage years as a young woman. It is an absolutely priceless experience if a transsexual girl goes through her adolescence as a female, with a circle of same-sex girlfriends. It's a period of time when her personality, identity and attitudes are forming, and the stage for the rest of her life is being set. She will have irreplaceable girlish memories and social adjustments that a transition later in life can never give her. Her life experience will be much more like that of other women, she will be able to talk more easily about parts of her past, her school days, and even have photos to show her future partners. For many girls, denying these experiences to her and enforcing an unwanted male gender is simply disastrous.

One successful transsexual woman "Anna Taylor" describes her early experiences: "It never occurred to me that I was a boy. I just wondered why I had something extra. I had sessions with a child psychologist and my parents were told to bring me up neutrally. My mother tried, but my dad would slap me if he caught me playing with dolls. My mother says that if it had been up to her she would have banged on every door to let me become a girl, but my dad wouldn't stand for it."

Anna ran away from home several times until, aged eight, she went to live with her grandparents who were prepared to bring her up as a girl. At age eleven she started at a new school where the headmaster was very sympathetic and agreed to let her register as a girl. "For the first time no one was laughing at me. From being very withdrawn, I became very bubbly and outgoing. The only allowance they made was that I had to change in a separate cubicle for games and use the teachers' toilets. The school was afraid of another girl seeing something they shouldn't. [But} I got very depressed when the other girls started wearing bras. My own doctor wouldn't prescribe hormones for me at thirteen, so my grandmother took me to Amsterdam to find a doctor who would. Within a few months I'd grown very small breasts. Doctors agreed that I should have had gender reassignment surgery when I was younger but now that I was an adolescent, I would have to wait until I was eighteen."

A recent follow-up study of sex-reassignment in twenty-two adolescent transsexuals (ten started hormones under age sixteen, twelve under eighteen) found that after surgery in all cases all signs of gender dysphoria had disappeared, they scored normally in psychological tests and they were socially functioning well. Not a single girl/boy expressed feelings of regret concerning their decisions to undergo sex reassignment. The study concluded that with careful preliminary screening, starting sex reassignment procedures before adulthood results in favourable post-operative functioning.

Puberty

Puberty can be defined as the biological developments which change boys and girls from physical immaturity to biological maturity. For a transsexual child an inappropriate puberty sets a mountain that can never be fully conquered, while an appropriate puberty offers a greatly eased path to gender reassignment, both physically and psychologically.

Puberty is often a nightmare for "gender dysphoria" children according to Cohen Kettenis, Professor of Psychology at the Medical Centre of the Free University in Amsterdam, "They develop an enormous dislike for their body." Most children seen by Professor Cohen react with horror to the changes that occur in their bodies at puberty. It appears that their so-called "transsexual" feelings become much stronger and they do not feel at home in the body that they now develop. Margaret Griffiths of the Mermaids support group says very similar things, "Some girls and boys go through hell at puberty, they have few friends, they are bad in school, because they can concentrate on nothing, and some have suicidal thoughts."

When Riley (who had been living as a girl since age seven, after threatening to kill himself) was warned by her mother when age ten that in a few years time nature would start turning you in to a man. Her reaction was horrified "Please don't let that happen ... please!".

Although the child may not admit to his transsexual desires at this stage, the parents will often start to have some concerns about their son. The onset of puberty is a critical point as the child is faced with his own undesired physical masculinisation, often combined with a great jealousy of girls and their physical changes.

By age fifteen some 90 percent are exhibiting feminine behaviour. This is the point where many transsexual children finally admit to their wish to be a girl and they, or their parents, seek help.

One now happily post-S.R.S. girl described how she felt at puberty: "That was the hardest. My own body was staging a mutiny, even." At sixteen she finally confessed to her secret to her parents who took her to several doctors but they wouldn't help, "I knew I couldn't be happy letting my body masculinise on and on. And so at seventeen I graduated from high school and found hormones on the street."

Now twenty-one, Zoe concurs about puberty: "When puberty arrived I was repelled by my erections and deepening voice. At times I felt suicidal. "Jamie Cooper was twelve when she wrote her mother a letter saying that she should have been born a girl, they sought medical advice and were told that it could just be puberty, the feelings deepened but she had to wait until she was sixteen before receiving hormone treatment - she transitioned on her sixteenth birthday.

Hormones and Puberty

Body shape is controlled by oestrogen and testosterone. During puberty, while boys are amassing bone and muscle thanks to their developed testes pumping out androgens (particularly testosterone), a high concentration of oestrogen in the female body results in the typical girl gaining nearly 35 pounds (15kg) of so called reproductive fat deposited on the hips and thighs rather than on the waist. Another female hormone, progesterone, also plays a significant and complementary role, most particularly in the development of breast tissue.

Professor Cohen's policy is that if it appears that the gender dysphoria feelings are becoming stronger then puberty blockers should be prescribed to temporarily halt puberty until they are sixteen. When they are sixteen, and quite certain that they have the wrong body, they can be prescribed hormones as well as to begin to change their outward appearance to more closely match their chosen sex. "After that comes the actual sex-change operation".

Hormone Treatment for Young Transsexual Girls

Ideally, in order to maximise the physical benefits, low level oestrogen treatment of the young transsexual boy-to-girl should begin at age eight to nine years. Before the onset of male puberty (at about age eleven, but can vary ± two years) a bilateral orchidectomy (castration) should be performed to remove both testes and hormonal treatment then increased (additional oestrogen, later supplemented with progesterone) to initiate a female type puberty.

When an orchidectomy is done before puberty, the results in terms of increased physical feminisation and decreased masculinisation are much more dramatic than when it is done after puberty.

Even if this pre-puberty ideal is not possible, the female hormonal treatment of the transsexual boy-to-girl can still have remarkable results if begun while the body is still at its most receptive age - the critical puberty years between about eleven and seventeen (depending on the individual), but the earlier the better.

It is no coincidence that so many transsexual women who famed for their looks had begun taking hormones by seventeen - Jenny Hiloudaki, Tula, Harisu, Roberta Close, Dana International, etc.

Doctors certainly seem to agree that giving, for example, a thirteen-year-old transsexual boy-to-girl doses of oestrogen will make her physically far more attractive as an adult women. However they also agonise about the possible negative consequences - and perhaps their potential legal liabilities from prescribing female hormones to "boys".

As a poor alternative to beginning full female hormone treatment in a young transsexual boy-to-girl, many medical specialists (who are often reluctant to start irreversibly feminising hormonal treatment until the girl is at least age sixteen) instead prescribe a GnRH analogue such as Zoladex (Goserelin Acetate) or Lupron (Leuprolide Acetate) which prevents or dramatically reduces gonadal hormone production, including testosterone, thus preventing the onset of the masculinising changes of adolescence.

The drugs are normally administered with a nasal spray, or via a weekly or monthly subcutaneous injection into the abdomen. While this treatment does nothing to promote female physical characteristics in the girl, it does at least prevent or greatly slow a male type puberty with its physical effects, and Dutch studies have recently confirmed the effectiveness of such treatment.

Unfortunately GnRH analogues are expensive drugs, but they are preferable for adolescents over the cheaper anti-androgens such as Aldactone (Spironolactone) and Androcur (Cyproterone Acetate) which are commonly prescribed to post-puberty transsexual women.

Young transsexuals often struggle to understand the medical "best practice" guidelines that affect their life. "When Riley was twelve she was to start taking both oestrogen and testosterone blockers. It had been explained to her that this would make her body more feminine! Her voice would not deepen and she would develop breasts - but that she would be infertile. Her reaction was "But I can adopt babies why can't the doctors take my testicles off now?"

A rare example of the medical community responding to the needs of young transsexuals was achieved in Germany when it was revealed in 2007 that doctors had prescribed puberty blocking and later female hormones to a twelve year-old Kim, formerly Tim.

At age two, Tim was trying on his older sister's clothes, playing with Barbie dolls and saying "I'm a girl." By age four Tim was refusing to get his hair cut and wanted to cut off his "thing". For the sake of a normal life his parents increasingly accepted their son Tim as being their daughter Kim. The situation reached a crisis when Kim grew increasingly distressed at becoming like other adult transsexuals with big hands and deep voices whom she thought looked ridiculous when they dressed like women. Her father said "We saw Kim as a girl ... not as a problem ... [she] reacted badly to the first signs of puberty ... At that stage we realised that she was terrified of breaking".

Kim's parents decided to help her get a sex-change and consulted psychiatrists across Germany. Some condemned their support of their child's desire to undergo a sex-change, or suggested that she be kept under observation in a closed psychiatric ward. But Dr. Bern Meyenburg, the head of a clinic for children and adolescents with identity disturbances at Frankfurt University concluded that the child was serious. He wrote in his diagnosis: "Kim is a mentally well-developed child who appears happy and balanced. "There is no doubt of the determined wish, which was already detectable since early childhood. It would have been very wrong to let Kim grow up to be a man."

Dr. Meyenburg had once strongly opposed hormone treatment for children but changed his mind when one of his patients refused to listen and ordered hormones over the Internet, then went abroad at seventeen and had a sex-change operation for a few thousand Euros. Dr. Meyenburg admits that he was angry at the time, but said that today the woman is a law student and one of his happiest patients. He now allows young patients to enter hormone treatment early, before puberty complicates a sex-change. "They simply suffer less," he said, "it would have been a crime to let Kim grow up as a man".

Dr. Achim Wuesthof, who is now treating Kim at a clinic in Hamburg, said: "Imagine a man who suddenly starts growing breasts or a woman who starts growing a beard against their will - that is how Kim and people like her experience puberty."

Kim was thus prescribed female hormone therapy when just twelve, and by age fourteen was fully transitioned and living as a girl - with her identity and medical insurance cards changed to her new name and female sex. By special dispensation she was allowed to have sex-assignment surgery at the age of sixteen although German law will normally only allow this at the age of eighteen.

Effects of Early Hormonal Treatment

Early hormone use (i.e. during puberty) in a trans-girl allows a typically normal female body shape to develop, with significantly more fat and less muscle than otherwise, the girls post-puberty body shape and "figure" will become far closer to female than male norms in its proportions. In general, increased levels in the blood plasma of oestrogen and progesterone will stimulate and promote the growth of female secondary sexual characteristics (breasts, fat distribution, pubic hair pattern ... ) while the reduction in the levels of androgens such as testosterone will, if early enough, completely prevent the development of male ones (deepening of voice, facial hair, muscular development ... ).

Female hormonal treatment has a dramatically greater effect if begun before a male puberty has started (on average age twelve, but plus or minus two years) than after a male puberty has completed (on average seventeen, plus or minus). This is a severe problem given the great reluctance of doctors to assist transsexual patients under age eighteen. Incidentally, the anticipated and achievable benefits from starting female hormones decline rapidly in the decade after puberty ends.

Maximum possible feminisation occurs if hormonal treatment begins just before a male puberty would have start started. Very conveniently, girls tend to start puberty two years earlier than their male peers, so high doses hormone therapy intended to initiate a full female type can be safely started by age eleven, although in practice it is often deferred to twelve or even later, particularly if the individual's physical development allows that. If her testes were removed in infancy or childhood, then for health reasons low level hormone therapy should be begun by age nine - an age at which many girls begin to notice some initial puberty changes, in particular the development of breast buds.

As indicated already, surgeons have become very reluctant in recent years to perform a bilateral orchidectomy (castration) on even young intersexed patients, let alone gender dysphoric boys. Failure to do so, however, does accept the slight risk that even suppressed testes might produce enough androgens for a very sensitive body to react to them. The nightmare scenario is a confused body going through a double male and female puberty - the girls hips broaden and her breasts swell under the influence of oestrogen therapy, but simultaneously her voice deepens and facial hair appears due to the testosterone being produced by her testes.

There seems to be no consensus amongst clinicians as to whether pubertal development is more "natural" in XY girls with oestrogen producing ovaries, than in XY girls (more commonly intersexed rather than transsexual) taking hormone replacement therapy (H.R.T.) following early orchidectomy. This lack of consensus can actually be considered a good indication of the great effectiveness of early hormone therapy.

The reduction in levels of "male" androgen hormones caused by oestrogen treatment will also have some slight affect on the skeleton - reducing male type "ruggedisation" and enhancing female type features, for example slightly broadening the pelvis and helping reduce the girl's adult height (by perhaps an inch or two) compared with her height if she had experienced a male puberty. While hormones play an important role in post-pubertal body shape, however, it's thought that the male "Y" chromosome is mainly responsible for skeletal growth. As a trans-girl is genetically "XY" she will thus still experience some degree of skeletal masculinisation, even if she commences female hormone treatment at eleven or twelve. In general, her physical characteristics as determined by her skeleton (height, skull, hand and foot size) will lie between the male and female norms post-puberty - although more towards the former than the later. This is not necessarily bad as the western idea of feminine beauty is for tall and leggy women. As an adult, the woman will typically be both tall compared to the average woman (67.5 inches versus 64.25 inches) and have long legs - both absolutely (32.5 inches versus 30 inches) and relative for her height, ideal for those girls with ambitions as a model!

In a genetic girl, her increasing production of oestrogen during puberty causes her skeleton to mature so that growth eventually stops. Oestrogen treatment can speed up this bone maturation by accelerating the completion of growth in the growth plates (the zones of growing cartilage near the ends of children's bones) and thus suppresses growth somewhat, by up to two inches. Paediatric endocrinologist sometimes prescribe large doses of oestrogen (usually Efflinyl Oestradiol) for a period of several years to deliberately restrict growth in excessively tall girls, and the same technique can be used to help induce in young transsexuals a final height in the typical female range 66 inches - 67 inches. However, obtaining supervised treatment for a transsexual boy-to-girl is difficult, arguing that height is not a disease, endocrinologists are becoming increasingly reluctant to treat even a genetically female "XX" adolescent unless bone growth X-rays show that excessive adult height for a female (over 71 inches) appears likely.

Commencing treatment during puberty will produce mixed results - e.g. the voice may have already deepened irreversibly but facial hair growth is prevented or greatly reduced.

Overall, the physical results of early hormonal treatment should be extremely successful, the girl developing a well feminised physique with full breasts (although rarely as large as the girl would like), no beard, plentiful scalp hair, and an unbroken female type voice. It's difficult to over-exaggerate just how great these advantages are, and how much of a disaster each year of delay is for the transsexual girl whose skeleton and body is rapidly turning into that of a man. The end of puberty is a fundamental and irreversible physical marker, from which the plausible effects of feminising hormonal treatments on the body of a trans girl/woman decline with depressingly rapid speed. For any transsexual woman starting treatment when already physically mature (and this merely means age twenty onwards), a muscular and robust stature; a deep and masculine sounding voice; obvious facial beard growth; and a receding hairline, are just four of the immediate challenges that may seriously threaten her ability to pass convincingly as a woman. She also faces the high cost of electrolysis, breast augmentation, facial feminisation, etc.

Desired CharacteristicHormone Treatment Pre-PubertyHormone Treatment Post-Puberty
Prevent skeletal masculinisation, e.g.. large hands and feet; square jaw Some benefit (e.g.. growth may terminate earlier, less heavy bones) No
Relatively lower height than men Some benefit (Excessive early oestrogen intake can actually result in stunted growth and below average female height) No
Broad female type pelvis Some benefit No
Small Nose Possibly some benefit No
Soft clear skin, with no acne or spots Yes - i.e. within normal female limits Substantial improvement
Prevent facial beard hair Yes Little or no effect
Thick female type scalp hair and forehead hairline Yes Hair loss ceases, slight reversal of balding
Female pubic hair pattern. Hairless trunk and limbs. Yes Substantial improvement after prolonged treatment
Feminine type voice Yes for most children (Prevents the dropping of the larynx, also known as the breaking of the voice) No
Slim neck Possibly some benefit No effect that's not ascribable to dieting or surgery.
 No "Adams Apple" Yes No, surgery required
Minimise muscular development Yes Some reduction
Female type subcutaneous fat deposits and body contours (See note 2) Yes Variable redistribution. Increased fat deposits most significant on hips, buttocks & thighs after prolonged treatment
Small waist (See note 2) Some benefit May actually increase unless supported by dieting and exercise.
Maximise breast development (See note 3) Yes. Possibility of full and mature "Tanner V" breasts Variable from slight to substantial breast development, Tanner 5 very unlikely.

Notes:

Photos from The Teen and Transgender Comparative Study. This compares adult transsexual women with girls of puberty age (12-14) that have similar general characteristics.) image courtesy Charlie White Studio

  1. Effects of hormone treatment vary considerably by individual, and can take two to five years to fully achieve. The longer after male puberty that female hormone therapy is started the less effective it will be - and the effects decline rapidly rather than on a linear scale. Example: results are considerably more dramatic with an eighteen-year-old than a twenty-eight-year-old, but not usually very different between a thirty-eight-year-old and a forty-eight-year-old. Other treatments can help feminise some characteristics in adult transsexuals.
  2. Male-to-female transsexuals have a tendency to gain weight after starting hormones. Sensible dieting and suitable exercising (e.g. aerobics, not power lifting!) can greatly assist and magnify the effects of hormones in developing a female type figure and body shape. The objective should be a nicely rounded waist-hip ratio (W.H.R.) of 0.7 - 0.8, a range which is a key visual "female indicator". [As is now well known, a few young women diet to excess by various means - and some M.T.F. transsexuals do the same]
  3. Breast development will vary considerably depending on the individuals genetic make-up and the time from puberty. From hormones alone, a typical "natural" result in young transsexuals is one bra cup size less than the girls mother and sisters.

Hormone Regimens in Transsexual Girls

There seems to have been little published research with regard to the dosage of hormones in young transsexual patients, however research which relates primarily to Androgen Insensitivity Syndrome (A.I.S.) patients may be applicable to transsexual girls. Zachmann et al. cite one A.I.S. patient who had undergone orchidectomy in whom oestrogen administration was started at the earliest estimated pubertal age of 10.3 years in the form of Premarin 0.625mg three times weekly. It was found, however, that this stopped growth of the girl prematurely and the authors felt that it would have been better to have given the patient 0.005 - 0.01mg ethinyl oestradiol daily, instead. From studies of patients with Turner syndrome it has been suggested that to ensure normal pubertal growth, physiologic oestrogen replacement should be started at the appropriate bone age of about eleven years and should not be delayed in the hope of achieving a greater mature height. Batch et al. suggest a regime of five micrograms of ethinyl oestradiol daily for the first six months, increasing to 20 micrograms daily by the end of puberty.

Soule et al. suggest that the best course of action may be to perform an orchidectomy just before puberty (at eleven years in a case quoted) followed by oestrogen therapy with regular bone density measurements. This policy, it is suggested, reduces any slight risk of malignant transformation of the gonads and ensures adequate oestrogen activity throughout the critical years of bone accretion.

Oestrogen levels are, however, higher in XX girls than in XY boys, even in childhood. XX girls start producing oestrogen at eight or nine (i.e. a year or two before breast development) so several clinicians therefore recommend early oestrogen supplements in XY girls, irrespective of whether or not the gonads are in place.

Early hormone treatment is not a miracle, but the benefits such as female hair pattern, breast development no beard growth, no Adams apple, no broken (deep) voice, are immense.

Females Hormones and Attractiveness

A very awkward problem for psychologists advocating delayed hormonal treatment for young trans girls is that as a result they will be physically less attractive as a woman to men.

There is a strong and direct correlation between the level of a girls oestrogen levels during puberty and how attractive and feminine she is perceived as a woman. For example the hormone has lasting effects on bone growth and tissue formation as well as the appearance of the skin during the average seven-year-long puberty. Miriam Law Smith of the University of St. Andrews states the hormone has a crucial role in determining facial appearance, giving thirteen year old's doses of oestrogen will "certainly make them more attractive [to men]" although she adds "who knows what other effects the hormone may have?" As regards the last comment, pubertal girls who have been prescribed oestrogen to prevent excessive height (over six feet) may, according to one study, subsequently suffer from lower fertility.

Passing and Sexual Orientation

There seem to have been no formal clinical studies, but it seems certain that young male-to-female women are far more likely to complete their transition and settle well into their new lives than those who transition at a later age. It is also very likely that a far higher percentage of young transsexual women identify themselves as heterosexually attracted to men than when compared to older transwomen.

Fourteen year-old Jamie (left) and Fifteen year-old Danique are unambiguously girls after their transition. (Netherlands)

About 95 percent of natal "XX" women consider themselves as being heterosexual. By comparison, studies of the sexual orientation of post-S.R.S. transsexual women indicate that only half are heterosexual and exclusively select males as sexual partners; nearly one-fifth are lesbian and sexually attracted only to females; and about one-third are bisexual. However these studies cover all age groups (with an average age in the thirties or even forties), and are almost certainly not representative of the relatively few young transsexuals who transition before the completion of their male puberty. For under twenty-one year olds, I would suggest that there are very few girls who do not consider themselves to be heterosexual, and have or would like to have, a boyfriend.

Unlike older transsexual women, young transsexual girls rarely have had any sexual activity before they transition, and if they do it's likely to be of a homosexual nature, generally playing a female role during intercourse. Mentally they are often only erotically stimulated by men, although overall their sexual urges may be very low because of puberty suppressants. When released from such drugs and placed on hormone therapy, they become just as interested in boys and men and sex as other girls of their age - if not more so. "G", a nearly sixteen-year-old trans girl undergoing an intense female puberty thanks to being on hormones illicitly obtained by her parents, may be quite typical when she writes: "I can't stop thinking about my [neo-vagina]... I want to be ["screwed"] by any guy in sight. I was even thinking about my teachers and my best friend's dad." But this girl does not expect to undergo S.R.S. for years yet.

Unlike older transsexual women, young transsexual girls rarely have any problems passing easily and naturally and assimilating themselves as women. For example, in one survey (Sex Reassignment of Adolescent Transsexuals: A Follow-up Study, Cohen, 1997) of young transsexuals, all the male-to-females were satisfied with their appearance after hormone therapy, and it was the interviewer's observation that it was difficult to discern any signs of their [genetic] sex. Most of the girls had been approached in a flirtatious manner, and not one had been approached by strangers as if they were still of the male sex, 60 percent expressed satisfaction with their vaginoplasty, and had experienced sexual intercourse without problems. The author of the study suggested that part of the adolescents' success was due to the fact that they more easily pass in the desired gender role because of their convincing appearance. With one exception the voices of the girls were not male sounding, and early anti-androgen treatment apparently had acted in a timely way to block facial hair growth and the lowering of the voice.

Somewhat disputably, the study also stated: "Another aspect of this relatively positive outcome may be attributable to the criteria for treatment eligibility. ... [The] patients selected for early treatment not only are among the best-functioning applicants, but probably they also belong to the sub-type of so-called "homosexual transsexuals" (that is, individuals who are, before S.R.S., sexually attracted to same-sex partners) ... They are also referred to as "primary" or "early-onset" transsexuals."

An early transition seems to make passing and relationships with men much easier.

Nevertheless, success in passing may well be an important factor in young trans-girls being far more likely to have a heterosexual sexual orientation than transsexuals who transition as adults. It's clear that trans-women who transition at a young age are almost always physically able to go stealth, they typically do as soon as possible, and often quickly begin to have boyfriends and eventually a husband. The desire for a normal relationship with a man tends to pull the transwoman away from any open acknowledgement of her transsexuality and male past, as she feels (unfortunately often correctly) that the relationship may not survive the revelation. In the balance between personal happiness and revealing "the whole truth and nothing but the truth", most people choose happiness. The experience of this site is that when a young transsexual outs herself, she often soon regrets it - and for good reasons.

Sex Re-assignment Surgery

After hormones and transition, the next and final step is sex-reassignment surgery. Extraordinarily, only about one percent of S.R.S. operations performed by western surgeons are on girls under age twenty (and almost all of these are eighteen or nineteen). The reasons seem to be a combination of the Standards of Care guidelines, the need for a two year real life test when a hormone supported transition can only begin no earlier than age sixteen, money, the requirement for parental permissions in some countries, the reluctance of surgeons to operate on very young transsexuals, and the extreme rarity of under-twenty (or indeed under twenty-five) surgery candidates compared with older candidates - the median average age of European transwomen at the time of their S.R.S. is mid-to-late-thirties, with a mean average age of around forty.

By interesting contrast, one study of 195 Thai male-to-female transsexuals found that "many participants had transitioned very early in life, beginning to feel different from other males, and identifying as non-male by middle childhood. By adolescence many were living a transgendered life. Many took hormones, beginning to do so by a mean age of 16.3 years, and several from as early as ten years. Many underwent surgeries of various kinds, on average in the twenties, with one undergoing S.R.S. as early as fifteen years".

Clair (formerly Alex) Farley told her parents that she was gay when she was thirteen. After a suicide attempt at age fifteen she told a counsellor "I feel that I should be a girl". She finally transitioned at age eighteen and began hormones. "My hips widened, my thighs thickened and tiny breasts started to appear". She finally had her S.R.S. at age twenty-three, "a few days later I pulled out a hand mirror and got a first glimpse of my new vagina, it was badly bruised but I couldn't have been more excited, I was all woman".

Parental Support - Changing the Rules

Considering all the advantages of early treatment of the young transsexual, it's unsurprising that it is now increasingly demanded (and obtained) by increasingly knowledgeable transsexual children and their parents. Sources such as the Internet and television documentaries mean that children and parents are often no longer accepting as gospel the advice of an experienced and over-loaded doctor or psychiatrist. For example in 1997 there were an estimated 600 transitioned transsexual children (usually defined as under eighteen) in the U.K. A few years earlier the acknowledged figure would have been a handful. Another study published in November 2005 suggested that there were 2,000 young transsexuals in the U.K. age fifteen - nineteen, although with no further definition of their status. [Note: The figure of 600 excludes the very small proportion of "XY" intersex children born in the U.K. with ambiguous genitals who are assigned to the female gender by doctors while still babies, perhaps twenty - forty each year deriving from U.S.A. figures. There are also many children with "male" genes who were identified at birth as female and then brought up as girls, for example there are perhaps 3,000 "XY" women in the U.K. who were born with Androgen Insensitivity Syndrome.]

Supportive parents are undoubtedly influencing a "system" and a medical profession that was in the 1990's retreating rapidly from early treatment and accommodation of young transsexuals. After a decade-long reaction to the tragic David Reimer affair, it has become recognised that it is necessary to separate and differentiate between the voluntary and non-voluntary gender reassignment of children. While numbers are still small, there is nevertheless an increasing willingness by doctors and the "system" to support and aid the early reassignment of children. The revised guidelines in the current version 6 of the Standards of Care issued in 2001 makes it slightly easier for young transsexuals to officially obtain treatment, including puberty-delaying drugs.

But doctors still face circumstances where a failure to support young transsexuals in order to comply with guidelines can seem at best totally unreasonable. For example, in 2006 a five-year-old boy was allowed to enrol in kindergarten as a girl with a "gender-neutral name" in Florida, U.S.A., having been diagnosed with gender-identity dysphoria (G.I.D.) two years earlier. The parents said the child refused to wear boy's clothing and repeatedly said she hated having a penis - often trying to hide it between her legs. Officials said that there were already a number of trans students in the school system but none as young as kindergarten age, they expected that the youngster would go unnoticed as a girl. Can she be denied female hormones at age eleven-twelve?

Meanwhile, in Japan a seven-year-old boy with G.I.D., Ryoko Kanda, was allowed to enrol as a girl at a school in the prefecture of Hyogo, about 270 miles west of Tokyo after being diagnosed with gender-identity disorder at age six. The school has not told other parents about the switch, and a spokesman for the local school board said there had not been any complaints from other students or from the boy's parents since his enrolment. He stated that the boy's name is listed with girl students, she uses the girls' bathroom, attends a girls' gym class and wears a girl's swimsuit at the school pool.

The official also said "At this point, we are relieved that the child was accepted into [second] grade and is being raised in a healthy manner", he added that the school district would watch his case closely and reassess the decision as the boy reaches puberty. Katsuki Harima, a psychiatrist specializing in gender-identity disorder, said the decision to allow the boy to enrol as a girl seemed appropriate, but would get complicated as he grew older. Harima said the boy is not old enough to determine whether he really has the disorder. A boy who behaves like a girl does not necessarily have gender-identity disorder and he could discover as he grows older that he wants to be male.

Conclusion

There is no doubt that for the best possible final outcome, the sex-reassignment treatment of a gender dysphoric (i.e. transsexual) male-to-female boy/girl should be started as early as possible - ideally before puberty. Compared with the experiences of older transsexuals, the results are often almost magical. All the current evidence indicates that the under-eighteen trans girl will identify totally with her new female gender and appearance, passing well both psychologically, socially and physically; and be far more happy as a female and have no regrets. She will still face problems of course, such as hiding her lack of periods and admitting her inability to bear children to a potential husband, but these are a totally different set of problems from what a decade's delay would have imposed upon her - such as an inability to pass due to her beard, deep voice, a bald patch, in addition to having a wife and children. The Cohen study mentioned above concluded: "Even adolescent applicants who are functioning well will need a lot of guidance through the process of sex reassignment. However, provided they manage to pass S.R.S. without problems, they have a lot to gain. They can catch up with their peers and devote their attention to friendships, partnership, and career." It is unfortunate that the medical profession, while also advancing, is doing so very slowly, partially due to a lack of facilities and specialists. In the U.K. only one National Health Service Gender Identity Clinic, the Portman and Tavistock Clinic in London, is able to offer specialist psychiatric and endocrinology services for transsexual children - and this for a population of 58 million people!

Despite the improving situation - the transsexual who transitions while still under the age of eighteen rather than older remains very much the exception rather than the rule.

Final Note: I would like to give a huge thanks to all the girls who have contributed to this page in some way.

Polare Magazine is published quarterly in Australia by The Gender Centre Inc. which is funded by the Department of Family & Community Services under the S.A.A.P. program and supported by the N.S.W.Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion and debate on gender issues. Unsolicited contributions are welcome, the editor reserves the right to edit such contributions without notification. Any submission which appears in Polare may be published on our internet site. Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc., the Department of Family & Community Services or the N.S.W. Department of Health.

Town & Country Centre (Griffith)

MIA Gay & Lesbian Support Group offers support for all who identify as L.G.B.T. The centre provides a weekly drop-in, 24 hour telephone counselling and referral service, and has information on all health issues, coming-out, transgender, cross-dressing, bisexuality, men who have sex with men. They also provide support for parents, family and friends, youth, ethnic and Koori weekly social functions and a monthly newsletter.

  • (02) 6964 5524
  • 80 Benerembah Street, Griffith N.S.W. 2680
  • P.O. Box 2485 Griffith N.S.W. 2680 5071

Transbridge (Queensland)

Transbridge is a support group for transgenders in the Townsville area. They have connections with sexual health, mental health, H.I.V./AIDS counselling and others by association, and can be contacted for twenty-four hour support.

  • 0406 916 788
  • P.O. Box 3572, Hermit Park Qld. 4812

Transgender Anti-Violence Project

The Transgender Anti-Violence Project provides a range of free, confidential services including education, support, referrals and advocacy in relation to violence and oppression based on one's gender identity. The Project addresses all forms of violence that impact on the transgender, gender-diverse and gender-questioning community, including (but not limited to) domestic violence, sexual violence, anti-transgender harassment, hate crimes, verbal abuse, physical attacks, bullying, discrimination, stalking and family violence. They need to know about your experiences to be able to help you personally and to document the event in order to stop it from happening to others. When you make a report to the T.A.V.P. you will be assigned a support worker to assess the nature and level of support you may require. The Project will then provide ongoing assistance and referral services, including support when reporting to police, counselling, legal support, court support and medical support and follow-up support.

Transgender Resource and Advocacy Network (Wollongong)

Transgender Resource and Advocacy Network is a service for people who identify as a gender other than their birth gender and providing a safe and confidential place to visit, phone or talk about gender issues between 9:00am and 5:00pm, Thursday and Friday each week.

  • (02) 4226 1163

Transgender Victoria

Transgender Victoria was founded in the late 1990s to achieve justice, equity and quality health and community service provision for transgender people, their partners, families and friends. Transgender Victoria educates organisations and workplaces on how to provide better services for trans* people, and seeks ways to provide direct services to the trans* community, whether in partnership with others or independently. They also work with and for the transgender community to create positive change in human rights and policy development. They represent the transgender community in challenging discrimination and assist in the empowerment of trans* people so that they may lead full and meaningful lives. Transgender Victoria recognises the right to equality of each and every member of the transgender community in all areas of life including housing, education, work, health services and legal representation.

True Colours

True Colours seeks to be a place where the voices of the young people who experience difference or diversity can be heard and understood. True Colours is committed to building a network of support throughout Australia. This network will include medical professionals (doctors, psychologists etc), teachers and schools, legal practitioners and community leaders. Whether you are a parent, a family member, a carer, a friend or a young person experiencing the diversity in sexual formation called transsexualism, please contact us and let us know if you think you can help.

True Colours Program (Western Australia)

True Colours is an initiative of the Uniting Church in Western Australia and provides a safe and inclusive environment for young people with diverse sexuality and/or gender identities and their families. The program includes social peer support groups for young people between the age of 15 and 25; information, support and advocacy for young people (as well as their families and friends), who are exploring their sexuality and/or gender identity; referrals and links to allied youth and community support services; opportunities for young people to be involved in peer education, community development and other initiatives. The program also provides information and support to allied agencies and workplaces including schools under their 'Safer Schools Project'. True Colours is based in Bunbury and provides these services to the south west region of Western Australia.

Twenty10

Twenty 10 is a community based, non profit state-wide organisation that works with and support young people of diverse genders, sexes and sexualities, their families and friends. They aim to be a beacon of strength and acceptance - supporting young people to build resilience and achieve their potential. Twenty10 is a free and confidential service, offering a safe place for clients and staff deal with all enquiries in an understanding, supportive and confidential manner. Twenty10 provides support to young transgender, lesbian, gay and bisexual people who are having trouble at home or are homeless, they provide accommodation, support, counselling, case management and social support as well as information and referrals for young L.G.B.T. people and their families, and runs community education programs throughout N.S.W.

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