Tweet
For those who don't subscribe to the New Scientist, I thought this was one of the best articles on the current state of the art. In particular, it talks about the Thai Ladyboy Shortcut of which omits the GnRH blockers, which cost up to $1000 a month, and instead take extra-high doses of the target sex hormones. This is probably where many of the unique and unhealthy bits of being a ladyboy show up.
Here is the article.
Teenagers trapped in the wrong body
* 20 April 2007
* NewScientist.com news service
* Alison George
Last year Sally Jones* found her 13-year-old son Nick* with a knife in his hand, steeling himself to cut off his penis. Ever since he could talk, Nick has insisted he is really female, and at the age of 5 he announced: "God has made a mistake, I should have been born a girl."
Nick has long dressed as a girl, enduring constant bullying and assaults. When he reached puberty, however, matters reached a head. When Nick got erections he would scratch his skin raw, so Sally wasn't all that surprised to find her son preparing to cut off the part of his body he detested so much. "I've become used to dealing with crises," she says. "Sometimes it feels like I'm on suicide watch."
Nick's mind and body appear to be different sexes - a rare condition sometimes called gender identity disorder (GID). While most people are aware of transsexual adults, much less attention has been paid to what is essentially the same thing arising in adolescents and even young children. Adults can, if they are lucky, have a sex change, involving drug therapy and surgery. For anyone under 18 that has until recently not been an option. Now a few doctors have begun treating adolescents with drugs - even, in a few exceptional cases, children as young as 12.
It is an area that is fraught with difficulties, because some who experience GID as children grow into adults who are happy with their original sex. On the other hand, some children experience terrible distress as they go through puberty and acquire the sexual features of the gender they so vehemently reject. Suicide attempts are common. Even among specialists, there is fierce debate about the best approach. As Peggy Cohen-Kettenis, a Dutch psychologist, who has pioneered early treatment of children with GID, acknowledges: "Some people hate me for what I'm doing."
So what is GID? It is not simply a case of boys being effeminate or girls being tomboys - although affected children do reject the toys, activities and clothing typical of their gender. Boys with GID often assert that their penis is disgusting and will disappear. Girls commonly claim that they will grow a penis and say that they do not want to develop breasts or menstruate.
It is unclear how common GID is among children, but many transsexual adults say they felt they were "in the wrong body" from an early age. The incidence of adult transsexualism has been estimated at about 1 in 12,000 for male-to-females, and around in 1 in 30,000 for female-to-males, although transsexual lobby groups say the true figures may be far higher.
Some mental health professionals see transsexualism as a psychological condition, perhaps triggered by events in early childhood. Others argue that it has a biological cause, and research published in Nature in 1995 revealed that male-to-female transsexuals had a difference in a key area of the brain involved in sexual behaviour. For now, though, the exact interplay of nature and nurture remains a mystery.
Our physical gender is determined by our genes early on in the womb. Around three weeks after conception both male and female embryos have primitive "unisex" genitalia. At around eight weeks, testosterone produced by the developing male fetus triggers the development of male genitalia, while the absence of testosterone sends the fetus down a female development pathway.
It is still not clear how a "normal" sense of gender identity develops. We do know that children seem to develop an innate sense of being male or female very young, and by age 2 can identify which sex they belong to. By age 6, they have learned that gender is fixed - that they will stay male or female and won't change sex when they grow up. "Gender identity is not a matter of free choice," says Bern Meyenburg, a psychiatrist who runs a clinic for children and adolescents at the University of Frankfurt in Germany. "You are born with it or it is laid down in early life."
Puberty normally begins between the ages of 10 and 14 in boys and 9 and 13 in girls. The process is kick-started by the brain secreting a hormone called gonadotrophin-releasing hormone (GnRH). This triggers release of other hormones which ultimately lead to production of the sex hormones: in boys the testes make testosterone and in girls the ovaries make oestrogen. These hormones bring about a raft of changes, including the growth of pubic hair, the development of the genitals into their mature forms, and a gradual shift in body shape characteristic of the two sexes. Puberty can be difficult enough at the best of times, but developing breasts and menstruating when you believe you are a boy must be horrific. "For children with atypical gender development, puberty can be a very intense and distressing experience," says Domenico Di Ceglie, a child psychiatrist who runs the UK's Gender Identity Development Service for children and adolescents at the Tavistock Clinic in London.
€œDeveloping breasts and menstruating when you believe you are a boy must be horrific€
So what can doctors do to help? Even for transsexual adults, sex change treatment is controversial enough. Those with the condition have long had to battle a generally unsympathetic medical profession, with psychotherapy the main treatment on offer. Nowadays most western doctors accept that trying to help transsexual adults "change their mind" about their gender identity is not very helpful. The treatment of choice for many is now changing the body. The first step is usually rigorous psychological assessment, and most individuals are required to live for some months as their target gender to demonstrate their commitment.
Breathing space
After this, gender reassignment can begin. GnRH and the sex hormones (oestrogen and testosterone) are produced throughout life to maintain the healthy functioning of the reproductive organs as well as having a host of effects on other parts of the body. The first step, therefore, is to take drugs called GnRH blockers, which stop most production of natural sex hormones, before taking sex hormones of the target gender. In countries that lack state healthcare funding, an alternative approach is to omit the GnRH blockers, which cost up to $1000 a month, and instead take extra-high doses of the target sex hormones.
In a male-to-female transsexuals the treatment results in smaller testicles, a smaller physique, decrease in body hair, breast growth, and some redistribution of fat. A female-to-male patient experiences clitoral enlargement, a deeper voice, increased facial and body hair, and greater upper body strength. Some transsexual people then have surgery to remodel their genitals into the desired form, although the results can be variable. In addition, breasts can either be removed or implanted, and other types of plastic surgery are available to help someone look more like their target sex. Male-to-female transsexuals, for example, can have their jaw or Adam's apple modified.
The world leaders in sex change treatments for the young are a Dutch group at the Free University Medical Centre in Amsterdam, led by Cohen-Kettenis and hormone specialist Henriette Delemarre-van de Waal. Their first case was 15 years ago, a 12-year-old girl who Delemarre-van der Waal says was "clearly transsexual". "She was a very intelligent girl who was successful at school, but she was very depressed about going through puberty and was taping her breasts up," she says.
At the time GnRH blockers were already being used to put puberty on hold in children who began puberty earlier than normal, before the age of about eight. When the drugs are stopped, puberty resumes with no apparent side effects.
Although it had never been tried before Delemarre-van de Waal decided to give the drugs to her transsexual patient to see if it helped reduce her distress. "She did very well," recalls the doctor. "Psychologically, she was so much better." At the age of 17, she received testosterone therapy, and went on to have sex change surgery to become male. He is now a successful veterinarian. The Dutch team began to treat other similar cases in over-16s, with the proviso that they met a strict set of criteria. Most importantly, the teenagers had to undergo intensive psychological assessment to check they had profound and persistent GID, were otherwise psychologically stable, and had supportive families.
About six years ago the Dutch team began to treat younger children, giving only GnRH blockers to under-16s, because the effects are believed to be reversible. Once children reach 16 they can get the sex hormones of the target gender, to allow them to go through an artificial "trans" puberty. The doctors say their patients do better psychologically than those who are forced to go through puberty in their original gender. After all, if you are trying to be accepted as a woman, it helps if you are not 6 feet tall with a burgeoning moustache.
Over the past few years, a small number of other clinics around the world have started to follow the Dutch approach. In Australia, doctors went to court in 2004 to get permission to treat their first child, who was 13. Another case is also now going through the Australian courts. In Germany, meanwhile, 12-year-old Kim (formerly known as Tim) made headlines around the globe in February this year, incorrectly reported as the world's "youngest ever transsexual" (the Dutch team have long treated 12-year-olds).
These doctors believe that putting puberty on hold can give a valuable respite to teenagers in great anguish over their rapidly changing bodies. Sometimes a breathing space is all that's needed. Walter Meyer, a hormone specialist and psychiatrist at the University of Texas Medical Branch in Galveston, Texas, recalls a 15-year-old boy he put on blockers. Six months later the patient decided not to proceed with the sex change. "The blocker gave him time," says Meyer. "He didn't feel pressure and it took the edge off."
Such cases, however, are rare. In most countries, transsexual people have to wait until they are at least 18 for any kind of medical treatment. In the US, a few doctors will treat under-18s, but the prohibitive cost of GnRH blockers puts them out of reach of most.
Russell Viner, a hormone specialist who is part of the team responsible for the medical treatment of children referred to the UK's Gender Identity Development Service, favours a cautious approach. He sanctions GnRH blockers only for teenagers who have reached a relatively late stage of puberty (known as Tanner stage five), when most have attained their full height, around 15 or 16 years old.
No going back?
Viner and others have several major concerns about earlier treatment of GID. The first is that puberty is a fundamental process in the pathway of human development. As well as affecting the genitals, it boosts growth and bone density, and affects muscle mass and fat distribution. The ways that it affects brain development are only just beginning to emerge, and Viner fears that suppressing puberty soon after it begins could be harmful. "I am concerned about the effects of suppressing puberty very early, particularly on the brain, which is developing extremely quickly at this age," he says.
The Dutch team have found that when their patients get trans sex hormones, bone density increases, and in female-to-male patients there is a growth spurt. They also plan to investigate the effects on the brain of going through an artificial trans puberty.
However authentically the trans hormones can mimic puberty, there is as yet no medical treatment in the world that can give a transsexual person fertility in the target gender. "Can children at the age of 12 or 13 consent to give up future fertility?" asks Viner. "These are very difficult arguments."
Viner's biggest worry, however, is that early treatment risks giving potent drugs to children who might later change their minds. Some studies suggest that a significant number, perhaps even the majority, of children with an initial diagnosis of GID end up happy in their original gender - sometimes gay, sometimes straight.
Even children with the most extreme symptoms of GID may later have a change of heart. "Despite doing very comprehensive psychological assessments, we find that around 20 per cent of young people who are convinced they are transsexual change their mind at puberty," says Viner.
The Dutch team, however, who have given GnRH blockers to around 60 under-16s, say they have not had a single patient who has regretted their decision. Equally, hormone specialist Norman Spack from the Children's Hospital in Boston says he has treated around five young people with GID and has yet to find one who changed their mind. "I know that I'm going to be wrong one day," he admits, "but do I condemn 99 per cent of the others to misery because of that?"
On the other hand, it is possible that the drugs themselves could prevent some young people who are treated this early from changing their minds when they reach puberty. "We are unclear about the impact of pubertal hormones on gender identity development," says Di Ceglie. "We don't know how reversible these interventions are."
But not intervening also has some irreversible consequences. As Spack points out, waiting until puberty is almost completed "means they have to have more surgery to remove body parts, and there are some things about their physique that can't be changed".
Doctors who work in this area face immense pressure from their teenage patients. "They want everything - hormones and surgery - yesterday," says Ken Zucker, head of the child and adolescent gender identity clinic in Toronto, Canada. The lack of clear evidence about the natural progression of GID through puberty, and the effectiveness of the various treatments, just adds to this pressure. Plans are afoot to compare teenagers treated under the Dutch and UK protocols, but the results will not be available for several years.
There was no dilemma for the parents of Nick Jones, whose story was told earlier. Nick's mother didn't think her child would make it through puberty alive. Unable to get treatment in the UK, they now fly to see Spack in the US for regular prescriptions of GnRH blockers. Nick is now Nicky, and is eagerly waiting to start trans hormone therapy, and, when she is 18, sex change surgery. "The social ostracism Nicky would have faced as she became more male would be awful," says her mother. "If she had to go through male puberty, she would have killed herself."
The medical maxim "first do no harm" is put to the test by this condition. "The fear is that if we intervene, we do harm, but if we don't intervene, we can also do harm," says Cohen-Kettenis. That is the dilemma.
Here is the article.
Teenagers trapped in the wrong body
* 20 April 2007
* NewScientist.com news service
* Alison George
Last year Sally Jones* found her 13-year-old son Nick* with a knife in his hand, steeling himself to cut off his penis. Ever since he could talk, Nick has insisted he is really female, and at the age of 5 he announced: "God has made a mistake, I should have been born a girl."
Nick has long dressed as a girl, enduring constant bullying and assaults. When he reached puberty, however, matters reached a head. When Nick got erections he would scratch his skin raw, so Sally wasn't all that surprised to find her son preparing to cut off the part of his body he detested so much. "I've become used to dealing with crises," she says. "Sometimes it feels like I'm on suicide watch."
Nick's mind and body appear to be different sexes - a rare condition sometimes called gender identity disorder (GID). While most people are aware of transsexual adults, much less attention has been paid to what is essentially the same thing arising in adolescents and even young children. Adults can, if they are lucky, have a sex change, involving drug therapy and surgery. For anyone under 18 that has until recently not been an option. Now a few doctors have begun treating adolescents with drugs - even, in a few exceptional cases, children as young as 12.
It is an area that is fraught with difficulties, because some who experience GID as children grow into adults who are happy with their original sex. On the other hand, some children experience terrible distress as they go through puberty and acquire the sexual features of the gender they so vehemently reject. Suicide attempts are common. Even among specialists, there is fierce debate about the best approach. As Peggy Cohen-Kettenis, a Dutch psychologist, who has pioneered early treatment of children with GID, acknowledges: "Some people hate me for what I'm doing."
So what is GID? It is not simply a case of boys being effeminate or girls being tomboys - although affected children do reject the toys, activities and clothing typical of their gender. Boys with GID often assert that their penis is disgusting and will disappear. Girls commonly claim that they will grow a penis and say that they do not want to develop breasts or menstruate.
It is unclear how common GID is among children, but many transsexual adults say they felt they were "in the wrong body" from an early age. The incidence of adult transsexualism has been estimated at about 1 in 12,000 for male-to-females, and around in 1 in 30,000 for female-to-males, although transsexual lobby groups say the true figures may be far higher.
Some mental health professionals see transsexualism as a psychological condition, perhaps triggered by events in early childhood. Others argue that it has a biological cause, and research published in Nature in 1995 revealed that male-to-female transsexuals had a difference in a key area of the brain involved in sexual behaviour. For now, though, the exact interplay of nature and nurture remains a mystery.
Our physical gender is determined by our genes early on in the womb. Around three weeks after conception both male and female embryos have primitive "unisex" genitalia. At around eight weeks, testosterone produced by the developing male fetus triggers the development of male genitalia, while the absence of testosterone sends the fetus down a female development pathway.
It is still not clear how a "normal" sense of gender identity develops. We do know that children seem to develop an innate sense of being male or female very young, and by age 2 can identify which sex they belong to. By age 6, they have learned that gender is fixed - that they will stay male or female and won't change sex when they grow up. "Gender identity is not a matter of free choice," says Bern Meyenburg, a psychiatrist who runs a clinic for children and adolescents at the University of Frankfurt in Germany. "You are born with it or it is laid down in early life."
Puberty normally begins between the ages of 10 and 14 in boys and 9 and 13 in girls. The process is kick-started by the brain secreting a hormone called gonadotrophin-releasing hormone (GnRH). This triggers release of other hormones which ultimately lead to production of the sex hormones: in boys the testes make testosterone and in girls the ovaries make oestrogen. These hormones bring about a raft of changes, including the growth of pubic hair, the development of the genitals into their mature forms, and a gradual shift in body shape characteristic of the two sexes. Puberty can be difficult enough at the best of times, but developing breasts and menstruating when you believe you are a boy must be horrific. "For children with atypical gender development, puberty can be a very intense and distressing experience," says Domenico Di Ceglie, a child psychiatrist who runs the UK's Gender Identity Development Service for children and adolescents at the Tavistock Clinic in London.
€œDeveloping breasts and menstruating when you believe you are a boy must be horrific€
So what can doctors do to help? Even for transsexual adults, sex change treatment is controversial enough. Those with the condition have long had to battle a generally unsympathetic medical profession, with psychotherapy the main treatment on offer. Nowadays most western doctors accept that trying to help transsexual adults "change their mind" about their gender identity is not very helpful. The treatment of choice for many is now changing the body. The first step is usually rigorous psychological assessment, and most individuals are required to live for some months as their target gender to demonstrate their commitment.
Breathing space
After this, gender reassignment can begin. GnRH and the sex hormones (oestrogen and testosterone) are produced throughout life to maintain the healthy functioning of the reproductive organs as well as having a host of effects on other parts of the body. The first step, therefore, is to take drugs called GnRH blockers, which stop most production of natural sex hormones, before taking sex hormones of the target gender. In countries that lack state healthcare funding, an alternative approach is to omit the GnRH blockers, which cost up to $1000 a month, and instead take extra-high doses of the target sex hormones.
In a male-to-female transsexuals the treatment results in smaller testicles, a smaller physique, decrease in body hair, breast growth, and some redistribution of fat. A female-to-male patient experiences clitoral enlargement, a deeper voice, increased facial and body hair, and greater upper body strength. Some transsexual people then have surgery to remodel their genitals into the desired form, although the results can be variable. In addition, breasts can either be removed or implanted, and other types of plastic surgery are available to help someone look more like their target sex. Male-to-female transsexuals, for example, can have their jaw or Adam's apple modified.
The world leaders in sex change treatments for the young are a Dutch group at the Free University Medical Centre in Amsterdam, led by Cohen-Kettenis and hormone specialist Henriette Delemarre-van de Waal. Their first case was 15 years ago, a 12-year-old girl who Delemarre-van der Waal says was "clearly transsexual". "She was a very intelligent girl who was successful at school, but she was very depressed about going through puberty and was taping her breasts up," she says.
At the time GnRH blockers were already being used to put puberty on hold in children who began puberty earlier than normal, before the age of about eight. When the drugs are stopped, puberty resumes with no apparent side effects.
Although it had never been tried before Delemarre-van de Waal decided to give the drugs to her transsexual patient to see if it helped reduce her distress. "She did very well," recalls the doctor. "Psychologically, she was so much better." At the age of 17, she received testosterone therapy, and went on to have sex change surgery to become male. He is now a successful veterinarian. The Dutch team began to treat other similar cases in over-16s, with the proviso that they met a strict set of criteria. Most importantly, the teenagers had to undergo intensive psychological assessment to check they had profound and persistent GID, were otherwise psychologically stable, and had supportive families.
About six years ago the Dutch team began to treat younger children, giving only GnRH blockers to under-16s, because the effects are believed to be reversible. Once children reach 16 they can get the sex hormones of the target gender, to allow them to go through an artificial "trans" puberty. The doctors say their patients do better psychologically than those who are forced to go through puberty in their original gender. After all, if you are trying to be accepted as a woman, it helps if you are not 6 feet tall with a burgeoning moustache.
Over the past few years, a small number of other clinics around the world have started to follow the Dutch approach. In Australia, doctors went to court in 2004 to get permission to treat their first child, who was 13. Another case is also now going through the Australian courts. In Germany, meanwhile, 12-year-old Kim (formerly known as Tim) made headlines around the globe in February this year, incorrectly reported as the world's "youngest ever transsexual" (the Dutch team have long treated 12-year-olds).
These doctors believe that putting puberty on hold can give a valuable respite to teenagers in great anguish over their rapidly changing bodies. Sometimes a breathing space is all that's needed. Walter Meyer, a hormone specialist and psychiatrist at the University of Texas Medical Branch in Galveston, Texas, recalls a 15-year-old boy he put on blockers. Six months later the patient decided not to proceed with the sex change. "The blocker gave him time," says Meyer. "He didn't feel pressure and it took the edge off."
Such cases, however, are rare. In most countries, transsexual people have to wait until they are at least 18 for any kind of medical treatment. In the US, a few doctors will treat under-18s, but the prohibitive cost of GnRH blockers puts them out of reach of most.
Russell Viner, a hormone specialist who is part of the team responsible for the medical treatment of children referred to the UK's Gender Identity Development Service, favours a cautious approach. He sanctions GnRH blockers only for teenagers who have reached a relatively late stage of puberty (known as Tanner stage five), when most have attained their full height, around 15 or 16 years old.
No going back?
Viner and others have several major concerns about earlier treatment of GID. The first is that puberty is a fundamental process in the pathway of human development. As well as affecting the genitals, it boosts growth and bone density, and affects muscle mass and fat distribution. The ways that it affects brain development are only just beginning to emerge, and Viner fears that suppressing puberty soon after it begins could be harmful. "I am concerned about the effects of suppressing puberty very early, particularly on the brain, which is developing extremely quickly at this age," he says.
The Dutch team have found that when their patients get trans sex hormones, bone density increases, and in female-to-male patients there is a growth spurt. They also plan to investigate the effects on the brain of going through an artificial trans puberty.
However authentically the trans hormones can mimic puberty, there is as yet no medical treatment in the world that can give a transsexual person fertility in the target gender. "Can children at the age of 12 or 13 consent to give up future fertility?" asks Viner. "These are very difficult arguments."
Viner's biggest worry, however, is that early treatment risks giving potent drugs to children who might later change their minds. Some studies suggest that a significant number, perhaps even the majority, of children with an initial diagnosis of GID end up happy in their original gender - sometimes gay, sometimes straight.
Even children with the most extreme symptoms of GID may later have a change of heart. "Despite doing very comprehensive psychological assessments, we find that around 20 per cent of young people who are convinced they are transsexual change their mind at puberty," says Viner.
The Dutch team, however, who have given GnRH blockers to around 60 under-16s, say they have not had a single patient who has regretted their decision. Equally, hormone specialist Norman Spack from the Children's Hospital in Boston says he has treated around five young people with GID and has yet to find one who changed their mind. "I know that I'm going to be wrong one day," he admits, "but do I condemn 99 per cent of the others to misery because of that?"
On the other hand, it is possible that the drugs themselves could prevent some young people who are treated this early from changing their minds when they reach puberty. "We are unclear about the impact of pubertal hormones on gender identity development," says Di Ceglie. "We don't know how reversible these interventions are."
But not intervening also has some irreversible consequences. As Spack points out, waiting until puberty is almost completed "means they have to have more surgery to remove body parts, and there are some things about their physique that can't be changed".
Doctors who work in this area face immense pressure from their teenage patients. "They want everything - hormones and surgery - yesterday," says Ken Zucker, head of the child and adolescent gender identity clinic in Toronto, Canada. The lack of clear evidence about the natural progression of GID through puberty, and the effectiveness of the various treatments, just adds to this pressure. Plans are afoot to compare teenagers treated under the Dutch and UK protocols, but the results will not be available for several years.
There was no dilemma for the parents of Nick Jones, whose story was told earlier. Nick's mother didn't think her child would make it through puberty alive. Unable to get treatment in the UK, they now fly to see Spack in the US for regular prescriptions of GnRH blockers. Nick is now Nicky, and is eagerly waiting to start trans hormone therapy, and, when she is 18, sex change surgery. "The social ostracism Nicky would have faced as she became more male would be awful," says her mother. "If she had to go through male puberty, she would have killed herself."
The medical maxim "first do no harm" is put to the test by this condition. "The fear is that if we intervene, we do harm, but if we don't intervene, we can also do harm," says Cohen-Kettenis. That is the dilemma.
Comment