Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
Porto
Biomedical
Journal
ht
tp
:
/
/
www.portobiomedicaljournal.com/
Rostrum
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents
Guido
Giovanardi
Department
of
Dynamic
and
Clinic
Psychology,
Faculty
of
Medicine
and
Psychology,
Sapienza
University
of
Rome,
Rome,
Italy
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
10
June
2017
Accepted
14
June
2017
Available
online
xxx
Keywords:
Gender
dysphoria
Hormone
blockers
GnRH
analogues
Puberty
Transgender
a
b
s
t
r
a
c
t
In
recent
years,
the
use
of
gonadotropin-releasing
hormone
(GnRH)
analogues
in
adolescents
with
gender
dysphoria
(GD)
to
suppress
puberty
has
been
adopted
by
an
increasing
number
of
gender
clinics,
gener-
ating
controversial
debate.
This
short
essay
provides
an
overview
of
the
difficulties
associated
with
this
heterogeneous
group
of
adolescents
and
discusses
arguments
for
and
against
the
suspension
of
puberty.
Further,
it
reviews
the
main
follow-up
studies
conducted
in
some
of
the
world’s
largest
clinical
centres
for
gender-variant
children
and
adolescents.
©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
How
long
have
I
been
here,
what
a
question,
I’ve
often
wondered.
And
often
I
could
answer,
An
hour,
a
month,
a
year,
a
century,
depending
on
what
I
meant
by
here,
and
me,
and
being.
-Samuel
Beckett
Gender-variant
children
and
adolescents
compose
a
heteroge-
neous
group
of
persons
who
present
an
incongruence
between
their
perceived
gender
identity
and
the
gender
to
which
they
were
assigned
at
birth.
This
incongruence
can
cause
significant
distress
(gender
dysphoria)
and
may
require
clinical
intervention.
The
com-
plex
phenomenon
of
gender
dysphoria
(GD)
is
described
in
detail
in
the
5th
edition
of
the
Diagnostic
and
Statistical
Manual
of
Mental
Disorders
(DSM-5).1
Over
the
last
20
years,
youth
referrals
to
gender
clinics
have
dramatically
increased.
In
Europe,
the
two
largest
gender
clinics
for
children
and
adolescents
are
the
Gender
Identity
Development
Service
(GIDS)
in
London
and
the
VU
University
Medical
Center
in
Amsterdam.
Both
centres
have
witnessed
a
significant
increase
in
referrals
over
the
past
10
years
(e.g.
in
London,
referrals
increased
from
97
to
more
than
2000
between
2009/2010
and
2016/2017a),
along
with
an
impressive
decrease
in
the
mean
age
of
referred
clients
and
an
inversion
in
the
sex
ratio
of
referrals
to
favour
natal
females.2,3 Research
on
children
and
adolescents
with
GD
or
gender
variance
(GV)
is
sparse.
However,
some
findings
are
emerging.4,5 It
E-mail
address:
guido.giovanardi@uniroma1.it
aData
presented
by
Bernadette
Wren
at
the
conference
‘Hot
Topics
in
Child
Health:
Transgender
and
Gender
Diverse
Children
and
Adolescents’
held
at
the
Royal
College
of
Paediatrics
and
Child
Health,
London,
June
2017.
is
now
acknowledged,
for
instance,
that
children’s
GD/GV
persists
after
puberty
in
only
10–30
per
cent
of
all
cases;
when
it
does
not,
the
children
are
referred
to
as
‘desisters’.1,5 At
present,
there
is
no
way
to
predict
which
individuals
will
or
will
not
suffer
from
GD
into
adolescence
or
adulthood.
However,
‘persisters’,
whose
GD
contin-
ues
into
adolescence,
are
more
likely
to
experience
GD
in
adulthood
(to
a
degree
of
almost
80
per
cent).6,7
Whether
or
not
GD
persists,
gender-variant
children
are
at
risk
of
suffering
many
psychological
adversities,
mostly
linked
to
body
dissatisfaction
(e.g.8)
and
a
lack
of
acceptance
within
the
family
and
social
environment
(e.g.9).
Children
with
GD
have
been
shown
to
be
more
psychologically
vulnerable
in
comparison
to
the
gen-
eral
population
(e.g.10–12).
Their
psychological
problems
seem
to
be
of
a
more
internalised
nature
(e.g.
depression,
anxiety,
eating
disorders)
than
an
externalising
nature.10,12,13 However,
there
is
considerable
variability
across
studies
(for
an
overview,
see14).
For
these
children,
family
and
peer
relations
are
generally
poorer
than
for
non-referred
children
(e.g.10,15).
As
Bandini
and
colleagues16
point
out,
it
has
been
demonstrated
that
children
showing
gender
variance
are
at
higher
risk
for
maltreatment
and
abuse.17,18 More-
over,
some
studies
have
reported
a
high
frequency
in
trans
persons
of
childhood
sexual
and
physical
abuse,
perpetrated
by
parents
and
caregivers
(e.g.19–21).
Finally,
research
has
shown
that
trans
youth
are
at
higher
risk
of
self-harm,
suicidal
ideation
and
suicidal
attempts
(e.g.22–24).
To
address
the
clinical
needs
of
such
a
complex
population
and
to
reduce
their
risk,
specialised
centres
have
developed
var-
ious
models
of
intervention.
One
of
those,
on
which
this
short
essay
focuses,
is
the
use
of
hormone
blockers
to
suppress
puberty.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
2444-8664/©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
2
G.
Giovanardi
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
This
methodology
is
becoming
increasingly
common
in
several
specialised
centres.
The
intervention
was
developed
by
Dutch
clini-
cians
in
the
framework
of
a
combined
approach,
including
medical
therapies
as
well
as
psychotherapy,
social
intervention
and
family
work.25–28 It
consists
of
a
fully
reversible
medical
therapy
that
sus-
pends
pubertal
development.
Individuals
who
have
reached
Tanner
stage
2
or
329 and
are
considered
eligible
for
treatmentbare
admin-
istered
gonadotropin-releasing
hormone
(GnRH)
analogues,
which
temporarily
suspend
pubertal
development.
These
analogues
act
on
the
pituitary
gland,
inhibiting
hormone
secretion
and
tempo-
rarily
suppressing
the
endogenous
production
of
oestrogen
in
girls
and
testosterone
in
boys.
These
hormones
are
sometimes
called
‘blockers’,
because
they
prevent
the
development
of
secondary
sex
characteristics.
During
this
stage
of
treatment,
in
the
absence
of
pubertal
physical
changes,
the
child
is
guided
through
an
explo-
ration
of
other
gender
roles,
in
order
to
experience
congruence
with
the
presumed
innate
gender
identity.
As
Steensma
and
colleagues30
point
out,
the
suspension
provides
adolescents
with
GD
‘time
and
rest
before
making
definite
decisions
on
gender
reassignment
without
the
distress
of
developing
secondary
sex
characteristics’.
Cohen-Kettenis
and
colleagues27 consider
it
an
extended
diagnos-
tic
phase,
in
which
the
distress
that
the
physical
feminisation
or
masculinisation
was
producing
is
significantly
reduced.
For
these
authors,
the
early
suppression
entails
great
advantages
for
transi-
tioning
to
the
desired
role
throughout
one’s
life,
and
thus
minimises
the
harm
to
youth
and
maximises
their
opportunity
for
good
social
and
sexual
relationships.
The
process
of
passing
to
the
other
gender
is
made
significantly
easier.
The
child
normally
also
receives
psychological
assistance
in
determining
whether
or
not
to
proceed
to
hormone
therapy
–
specifically,
the
administration
of
cross-sex
hormones,
which
is
the
first
step
in
irreversible
gender
reassignment.
Alternatively,
she
or
he
may
interrupt
therapy
and
revert
to
the
assigned
gender.
Once
endogenous
sex
hormone
production
is
resumed,
the
pubertal
development
is
thought
to
restart
normally.31,32
Although
the
use
of
puberty
suppressants
is
described
in
inter-
national
guidelines,
there
is
no
consensus
in
the
Endocrine
Society
Guidelines
and
the
Standards
of
Care
of
the
World
Professional
Association
of
Transgender
Health.33,34 The
primary
risks
of
puber-
tal
suppression
include
adverse
effects
on
bone
mineralisation
(which
can
theoretically
be
reversed
with
cross-sex
hormone
treat-
ment)
and
compromised
fertility;
data
on
the
effects
on
brain
development
are
still
limited.26,35
Several
studies
have
proven
the
effectiveness
of
early
medical
interventions
and
the
safety
of
these
interventions
with
regard
to
physical
and
psychological
harm.
Overall,
research
has
shown
improved
psychological
functioning
during
suppression,
no
change
of
mind
in
terms
of
gender
identity
and
the
reduction
or
disap-
pearance
of
distress
related
to
GD;
in
addition,
several
studies
have
reported
an
increase
in
GD
and
harmful
behaviour
when
blockers
are
not
used.34,36
In
their
longitudinal
study
on
the
first
70
adolescents
to
receive
puberty
blockers,
de
Vries
and
colleagues37 reported
an
improve-
ment
in
general
functioning
after
two
years,
along
with
a
decrease
in
depression
and
behavioural
and
emotional
difficulties.
Fifty-five
of
these
70
individuals
were
assessed
later
in
early
adulthood,
after
cross-sex
hormones
had
been
administered
and
gender
bEligibility
criteria
for
hormone
blockers
are:
‘(i)
a
presence
of
gender
dyspho-
ria
from
early
childhood
on;
(ii)
an
increase
of
the
gender
dysphoria
after
the
first
pubertal
changes;
(iii)
an
absence
of
psychiatric
comorbidity
that
interferes
with
the
diagnostic
work-up
or
treatment;
(iv)
adequate
psychological
and
social
support
during
treatment;
and
(v)
a
demonstration
of
knowledge
and
understanding
of
the
effects
of
GnRH,
cross-sex
hormone
treatment,
surgery,
and
the
social
consequences
of
sex
reassignment’
(Cohen-Kettenis
et
al.,
2008,
p.
1894).
reassignment
surgery
had
been
performed.
Depressive
symptoms
had
decreased,
general
mental
health
functioning
had
improved
and
no
regret
about
transitioning
was
found.
Many
(about
70
per
cent)
reported
that
their
social
transition
had
been
‘easy’.
Cohen-Kettenis
and
colleagues,38 in
a
22-year
follow-up
of
the
first
described
adolescent
treated
with
GnRH
analogues
and
cross-sex
hormones,
reported
overall
improved
psychological
well-being
and
no
clinical
signs
of
adverse
effects
on
the
brain.
An
improvement
in
global
functioning
following
puberty
suppression
was
also
found
in
the
UK
study
of
Costa
and
colleagues39 in
their
follow-up
of
adolescents
at
the
GIDS
centre
in
London.
Consistent
with
the
Dutch
and
British
studies
was
Spack
and
colleagues’
report40 about
their
sample
of
97
patients
at
a
clinic
in
Boston,
MA,
in
which
no
adolescents
showed
regrets
regarding
puberty
blocking
or
subsequent
cross-sex
hormone
use.
However,
use
of
this
intervention
has
only
recently
begun,
so
no
other
follow-up
studies
are
available
and
many
questions
are
still
unanswered.
Thus,
many
professionals
remain
critical
about
the
puberty-blocking
treatment
(e.g.25,41,42).
The
primary
counter-
arguments
are
as
follows:
1.
At
Tanner
stage
2
or
3,
the
individual
is
not
sufficiently
mature
or
authentically
free
to
take
such
a
decision.25,41
2.
It
is
not
possible
to
make
a
certain
diagnosis
of
GD
in
adolescence,
because
in
this
phase,
gender
identity
is
still
fluctuating.25,41,42
3.
Moreover,
puberty
suppression
may
inhibit
a
‘spontaneous
formation
of
a
consistent
gender
identity,
which
sometimes
develops
through
the
“crisis
of
gender”’
(p.
375).43
4.
Considering
the
high
percentage
of
desisters,
early
somatic
treat-
ment
may
be
premature
and
inappropriate.25
5.
Research
about
the
effects
of
early
interventions
on
the
devel-
opment
of
bone
mass
and
growth
–
typical
events
of
hormonal
puberty
–
and
on
brain
development
is
still
limited,7so
we
can-
not
know
the
long-term
effects
on
a
large
number
of
cases.
6.
Although
current
research
suggests
that
there
are
no
effects
on
social,
emotional
and
school
functioning,
‘potential
effects
may
be
too
subtle
to
observe
during
the
follow-up
sessions
by
clinical
assessment
alone’
(p.
1895).25
7.
The
impact
on
sexuality
has
not
yet
been
studied,
but
the
restriction
of
sexual
appetite
brought
about
by
blockers
may
pre-
vent
the
adolescent
from
having
age-appropriate
socio-sexual
experiences.41
8.
In
light
of
this
fact,
early
interventions
may
interfere
with
the
patient’s
development
of
a
free
sexuality
and
may
limit
her
or
his
exploration
of
sexual
orientation.41,42
9.
Finally,
for
trans
girls
(natal
boys
with
a
female
gender
identifi-
cation),
the
blockage
of
phallic
growth
may
result
in
less
genital
tissue
available
for
an
optimal
vaginoplasty.44
Vrouenraets
and
colleagues45 conducted
a
remarkable
study
interviewing
various
professionals
of
17
treatment
teams
of
chil-
dren
and
adolescents
worldwide,
finding
that
the
majority
of
professionals
recognised
the
distress
of
teens
with
GD/GV
and
felt
that
early
intervention
was
urgently
needed.
At
the
same
time,
though
many
teams
embraced
the
so-called
‘Dutch
approach’,
a
general
feeling
of
unease
was
expressed,
due
to
the
lack
of
long-
term
physical
and
psychological
outcome
studies.
One
of
the
main
arguments
in
support
of
early
intervention
was
limiting
suicidal
risk.
Subsequently,
the
same
group46 interviewed
trans
adoles-
cents.
Surprisingly,
the
adolescents
also
seemed
cautious.
Many
had
doubts
about
the
ability
of
a
person
so
young
to
make
such
a
sig-
nificant
decision,
but
they
also
emphasised
the
capital
importance
of
preventing
the
development
of
secondary
sexual
characteristics.
The
adolescents
seriously
weighed
the
short-
and
long-term
con-
sequences
of
treatment,
but
this
awareness
did
not
stop
them
from
wanting
to
suspend
puberty.
Please
cite
this
article
in
press
as:
Giovanardi
G.
Buying
time
or
arresting
development?
The
dilemma
of
administering
hormone
blockers
in
trans
children
and
adolescents.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.06.001
ARTICLE IN PRESS
G Model
PBJ-92;
No.
of
Pages
4
G.
Giovanardi
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
3
Finally,
a
warning
comes
from
Alessandra
Lemma,
a
psychoana-
lytic
author
who
has
contributed
important
and
innovative
insights
into
transsexualism.47,48 In
a
recent
paper,
she
worryingly
suggests
that
in
some
instances
puberty
suppression
can
“result
in
a
marked
distortion
in
the
young
person’s
relationship
to
time”
(p.
361)49 that
will
negatively
impact
the
adaptation
and
integration
of
identity
following
gender
transition.
Conclusion
I
hope
that
this
brief
excursus
has
clarified
the
supporting
and
opposing
arguments
with
respect
to
the
use
of
hormone
blockers
to
suppress
puberty.
On
the
one
hand,
the
treatment
might
impede
experiences
that
are
seriously
traumatic
for
individuals
with
pro-
fessionally
and
accurately
diagnosed
GD,
limiting
suicidal
risk
and
preventing
other
adverse
psychological
consequences.
On
the
other
hand,
the
treatment
risks
hindering
the
individual’s
development
of
a
free
personality,
sexuality
and
identity,
thus
disconnecting
the
young
person
from
the
typical
experiences
of
her
or
his
age,
with
no
certainty
of
the
long-term
effects
on
physical
health.
Suppression
of
puberty
may
suggest
that
the
person
is
deprived
of
adolescence
–
the
crucial
time
to
deal
with
identity
issues,
experiment
and
pur-
sue
unstable
convictions
regarding
the
self.
However,
as
Bernadette
Wren
suggests,
there
is
no
evidence
that
“young
people’s
conviction
about
their
gender
identity
is,
typically,
as
unstable
as
other
value-
laden
convictions”
(p.
224).50 From
a
psychological
perspective,
the
main
dilemma
is
to
understand
whether
buying
time
at
such
a
precocious
age
truly
enables
children
to
explore
deep
personal
meanings,
or
whether
it
freezes
youngsters
in
a
prolonged
child-
hood,
secluding
them
from
certain
aspects
of
reality
and
isolating
them
from
peer
groups.
This
is
a
rather
difficult
issue
to
confront
in
quantitative
follow-up
studies
(which
of
course
are
crucial
for
mon-
itoring
physical
and
psychological
outcomes).
Thus,
qualitative
and
clinical
studies
may
have
a
great
deal
to
offer,
especially
when
con-
ducted
by
expert
clinicians
who
know
these
children
very
well.
In
any
case,
as
for
many
other
aspects
of
gender
identity
development,
it
is
crucial
that
a
person-by-person
approach
is
adopted
(as
per-
formed
by
the
abovementioned
gender
clinics)
to
tailor
effective
and
appropriate
interventions
according
to
individual
needs.
Conflicts
of
interest
The
author
declares
no
conflicts
of
interest.
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