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How important is age in transitioning?
by A. J. Smuskiewicz

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Robert Garofalo, MD, is well known to Windy City Times readers as one of the nation's foremost physicians specializing in adolescent medicine and treatment related to gender identity, sexuality, and HIV/AIDS.

With his base of patient care at the Ann & Robert H. Lurie Children's Hospital of Chicago, Garofalo treats hundreds of transgender patients, putting his extensive knowledge of the medical, scientific and social aspects of transgenderism to practical application in the clinical setting. Garofalo has been seeing young patients at his clinic since 2013, guiding them through the difficult steps of transitioning from one sex to the other.

Beginning treatment during adolescence may seem like the ideal option for transgender people, so Garofalo encounters such patients at an extremely crucial point in their lives. Drugs can be given to suppress their natural biological puberty development—thereby allowing them to avoid some of the body-versus-mind conflict with which older transgender people have to contend.

And hormones can be provided at an early age, allowing the individuals' bodies to develop sexually in ways that better match their gender identity. By contrast, older transgender patients who undergo gender transitioning through hormones and surgery must confront numerous physical and psychological challenges as well as social dilemmas stemming from the upheavals involved with moving from a male to a female life ( or vise versa ). Speaking from a purely personal perspective, this freelance writer has observed that friends and acquaintances of mine who transitioned in their teens appear to be much better adjusted, happier, and more confident and at peace with themselves than those who decided to transition later in life ( that is, past age 30 or 40 ).

However, what exactly does the available evidence and research indicate regarding the relationship between the timing of transitioning and the outcomes in patients ( in terms of physical, psychological, and social factors )? Garofalo recently discussed these and other issues.

Windy City Times: What are the age ranges of the patients you treat for gender identity? And what are the main ages that you work with?

Dr. Robert Garofalo: Our program sees patients who range in age from approximately 4 to 24 years. However, medical interventions or treatments, such as "pubertal blockers" and/or cross-gender hormones, are not used or even contemplated until young people are at least of pubertal age. As opposed to sexual orientation, which is considered an adolescent construct, gender-identity formation is considered more of a pediatric development process. Our program is available for all gender-nonconforming children or adolescents and their families.

WCT: What is the rough proportion of male-to-female versus female-to-male patients whom you have treated?

RG: In our program, we are currently seeing more transgender males ( whose sex assigned at birth was female ), with an approximately 60-percent-to-40-percent split. I think it is important to note, however, that many young people and children who are gender-nonconforming do not identify with a binary notion of gender ( male or female ). Rather, they tend to be more expansive in their gender identities.

WCT: According to your clinical experience, as well as published research, what are the advantages of beginning transitioning prior to or during puberty?

RG: First, it is important to note, again, that medical interventions aimed at transitioning are not initiated until after puberty has started. However, social gender transition is something that many families and children do initiate prior to puberty. Obviously, the main goal of transitioning is allowing a child to grow up and be nurtured, loved, and accepted as their authentic selves, rather than living as a gender or in a body that feels foreign or inauthentic.

There is a small but growing body of literature suggesting that family acceptance or support is a critically important component to helping these young people lead happy and successful lives. Our hope is that by initiating transitioning at earlier ages, many of the medical and psychosocial morbidities known to occur with increased frequency among transgender populations ( such as homelessness, HIV, depression, suicidal thoughts, and substance use ) might be ameliorated or—in an ideal world—eliminated as these young people lead authentic lives in their affirmed gender.

WCT: What are the cautions that young patients need to be especially aware of regarding transitioning ( such as adverse effects from hormone therapy or special social challenges )?

RG: There are many aspects of transitioning, particularly with such medications as pubertal blockers or cross-gender hormones, that require careful thought for patients and parents and that should be part of any consent process from qualified healthcare providers. The list of potential adverse effects from medications are not particularly well-studied, but they are too numerous to simply list as part of this interview. Nevertheless, with consistent and competent healthcare, the overwhelming majority of young people do exceptionally well and can tolerate the medical regimens without significant adverse effects.

WCT: Is there any age that may be too young to begin transitioning for certain individuals? For example, what if a 14-year-old genetic male thinks he might be transgender and wants to begin the transitioning process, but he is actually not transgender and is just temporarily confused about his sexuality—something he may not realize until after he passes through sexual maturity?

RG: This is a difficult question to answer. I am not sure there is an age that one would consider too young to begin transitioning, at least in terms of the aspects that are social in nature. Often, these decisions are faced by family members who simply want their child or children to be happy, to grow up in an affirming environment, and to be comfortable in their own skin and in their own bodies. The decision to socially transition a child is a family decision—not one that should be made by a medical provider. Our team is here to educate parents about what we know and, more often, do not know about the impact of social transition—and then to be there to support the families in making decisions that they feel will best support and nurture their child.

With regard to the initiation of medical interventions, part of the healthcare or medical treatment plan is to perform a careful assessment of readiness of each individual, whether it be for pubertal blockers or cross-gender hormones. There is debate within the medical community about the role of mental health providers in that process, but it is generally well-accepted that the only person who can determine a young person's gender identity is the young person themselves. I think, in general, the younger the patient, the more concern there may be about initiating medical therapies that may produce irreversible bodily changes.

Pubertal blockers can be used effectively in patients who may need additional time to consider whether cross-gender hormones are the right decision for them. Pubertal blockers, to some extent, act like "hitting a pause button" to prevent further pubertal development, which may be undesired but whose effects are generally considered reversible. Cross-gender hormones, which produce some irreversible effects, are not considered until a young person is at least 13 or 14 years of age, but, in most cases, they are initiated a bit later in adolescence.

WCT: According to published research, what is the approximate percentage of individuals who eventually regret transitioning? Is there any association between such regret and the age of transitioning?

RG: I do not think anyone knows the answer to such questions, as the research conducted in this area is scant. Anecdotally, very few of our patients express regret with regard to transitioning.

WCT: Do you find that each of your transgender patients has unique needs and concerns? Or do they tend to share many commonalities?

RG: While some transgender patients do share some commonalities, largely related to the challenges of growing up gender-nonconforming in a culture that is not always perceived as accepting, each patient must obviously be seen and cared for as an individual with unique needs and concerns. It is important to note that transgender adolescents are adolescents first and foremost. So while we as providers may want to focus attention on issues related to gender, the patients may prefer to focus on issues germane to any adolescent, such as acne, school problems, questions about dating or relationships, or seeking help navigating their autonomy from parents and family.

WCT: If you could say just one important thing to a child or teen who thinks he or she might be transgender, what would that be?

RG: I think it would be to stay true to themselves and to never stop being authentic. Transgender young people are among the most remarkably strong and resilient patients in medical practice and experience. We can learn a lot from these young people in so many aspects of our lives.

WCT: What is the status of your proposal with the NIH to conduct a study on the long-term effects of cross-sex hormone therapy on young people? Are you planning any other specific type of research?

RG: Our NIH grant is coming along very nicely. Each of the four sites [see below] is actively recruiting patients, and our hope is to be following these young people throughout their lives to help answer many of the questions you posed. There is still so much to learn about the safety and efficacy of our medical interventions and models of care. It is such an honor to be working with these children and families and to be doing this research at this moment in history. Our research will be among the first studies to be conducted in the United States looking at the medical, mental health, and social outcomes of initiating pubertal blockers and cross-gender hormones in children and adolescents.

In terms of other studies that we may be planning, there are quite a few. At Lurie Children's Hospital—again in collaboration with the other sites that form our Trans Youth Research Network ( University of California—San Francisco, Los Angeles Children's Hospital, Boston Children's Hospital )—we hope to begin to study a younger cohort of gender-nonconforming children to look at a number of outcomes, including the impact that social gender transition may have on the long-term health and well-being of these children. There are also questions that need to be answered about the future reproductive fertility options these young people may or may not have after medical interventions have been initiated. In general, medical outcome research for transgender populations is a nascent field in need of more work within a broad range of areas and disciplines.

Note: This is part of a series of articles summarizing scientific topics related to LGBT issues.

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