Hormone Treatment of Transsexual Adolescents

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Hormone Treatment of Transsexual Adolescents1
Achim Wüsthof
1 | Original version in German.
SUMMARY
A gender identity disorder in children and adolescents usually does not reveal any
anatomical, chromosomal or endocrinological deviations: the body is perceived
as being out of sync with the felt sex/gender which usually leads to considerable
psychological stress. Hormone treatment arrests the changes in puberty per-
ceived as extremely stressful and prevents irreversible changes such as deepen-
ing of the voice in biological boys or breast development in biological girls. Such
a treatment is only recommended after a thorough psychological assessment by
two independent gender experts from the field of child and adolescent psychia-
try; the Endokrinologikum Hamburg, where the author is employed, works in
close cooperation with the University Medical Centre Hamburg-Eppendorf. In
addition, the parents have to give their consent to a hormonal procedure. In gen-
eral, injections of GnRH analogues are used for suppressing puberty; also oral
medications (cyproterone acetate) can arrest masculinization and, occasionally,
gestagens are used to suppress menstrual bleeding. Once the adolescents then
go on to live their daily life over a longer period in the desired sex/gender, the
administration of cross-sex hormones (with estrogen or testosterone) has the
effect that the body aligns with the perceived sex/gender.
INTRODUCTION
Children who do not feel at home in their assigned sex/gender frequently ex-
press the desire for breasts if they have a penis or vice versa. Such remarks not
only cause confusion in their families but sometimes also overtax the attending
doctors. The children concerned are often for a long time left to their own devic-

190 Achim Wüsthof
es, unable to find anyone who is prepared to help them. And the treatment of
transgender children and adolescents with hormones is by no means uncontro-
versial in expert circles. The recurring issue is whether and when it is appropri-
ate to intervene with drugs in the development of puberty. In this article I would
like to report on our experiences at the Endokrinologikum Hamburg where we
have already advised and partly accompanied over the last 15 years more than 500
people with a gender dysphoria or a transsexual development.
Definition and frequency
Almost all of those seeking advice have a very similar history: already since early
childhood they feel as belonging to the other sex/gender. They reject their gen-
itals and wish to change their bodies in such a way that it harmonizes with the
sex/gender they feel themselves to be. How frequent are such gender identity
disorders? Medical literature supplies very varied incidence data – from 1:3.000
to 1:100.000 (Möller et al. 2009).
Causes
In their search for biological causes Australian researchers in Melbourne estab-
lished that the CAG repeats of the androgen receptor is longer in transsexual
women than in control subjects. Thus there could be a link between transsexu-
ality and an atypical interplay between hormones and corresponding receptors
(Hare et al. 2008). Also certain brain structures of transsexuals show similarities
to those of the desired gender (Zhou et al. 1995). So far however no unambiguous
biological explanations have emerged why a transsexual development occurs.
Controversies of hormone treatment
The question concerning the age at which adolescents should begin a therapy
is a point of much controversy among experts. A more guarded stance towards
hormone treatment of transsexual adolescents is adopted by child and adoles-
cent psychiatrist Alexander Korte from the University of Munich. He argues that
“considering the low rate of permanent transsexual developments in children
with a gender identity disorder, irreversible body-changing measures are indi-
cated at the earliest after psychosexual development is completed”. According
to Korte, the experiences that create identity through the body’s own hormones
should not be constrained by puberty-blocking LHRH analogues (Korte et al.
2008). At the VU (Vrije Universiteit) University Medical Center Amsterdam, by
contrast, puberty is suppressed from a Tanner stage 2-3 onwards (Tanner stage

191
Hormone Treatment of Transsexual Adolescents
2 in biological boys signifies a testes volume of > 3 ml and in biological girls an
incipient breast development).
The latter position, also favored by experienced Amsterdam colleagues such
as Peggy Cohen-Kettenis and Henriette Delamarre-van de Waal, is the one we
adopt in Hamburg. The precondition to starting treatment is of course that the
child and adolescent psychiatrist or psychologist have through careful evaluation
arrived at the conclusion that such a treatment is indicated. Then we first begin
with a GnRH analogue treatment, i.e. with drugs that put puberty into a state of
hibernation as it were.
Proponents of a later suppression of puberty such as the child and adoles-
cent psychiatrist Korte fear that a drug therapy could influence further develop-
ment iatrogenously, i.e. induced by medical measures. This is also taken up by
psychiatrists such as the sexual medicine specialist Hartmut Bosinski from Kiel
who argues that hormone treatment constituted a therapeutic suppression of a
homosexual orientation. The question of homosexuality thus has to be careful-
ly examined together with the adolescents concerned, because from a medical
perspective a same-sex sexual orientation is a considerably simpler procedure:
both medicalization and surgery can be dispensed with entirely and the individ-
uals becomes sexually active with their biological body. However, the majority of
transsexual adolescents were able to prove convincingly that theirs was not a case
of homosexual orientation.
But what then are the arguments for an early suppression of puberty? To
make it clear from the outset: in our view the advantages of an early treatment
outweigh the disadvantages. The main argument: irreversible changes in the
body, such as a deepening of the voice and growth of breasts, can be prevent-
ed. In addition, the adolescents are relieved of their psychological pressure, the
depressive symptoms usually diminish considerably, and where this is not the
case then this can be an indication that the diagnosis of transsexuality may be
incorrect after all.
There is an interesting study by Steensma et al. (2011) on desisters and per-
sisters conducted in the Netherlands: which patients adhere permanently to a
transsexual development and which do not? Here, the age between 10 and 13
seems to be a very decisive one. When puberty sets in there is either a reconcile-
ment with the biological sex or rejection increases dramatically. And when the
latter is the case treatment should not be postponed any longer.
In Amsterdam, cross-sex hormone therapy has until now been recommended
from the age of 16, which in many cases we find rather late, because this makes
2| Aufhörende und Bleibende.

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the adolescents differ markedly in their appearance from their peers. They then
live in the status of a neuter, which can be quite agonizing for them. In the Nether-
lands this age limit of 16 does however not always seems to be strictly observed
in practice, as can be inferred from informal conversations on the sidelines of
conferences.
A cross-sex hormone treatment can already be indicated when the transsex-
ual development has been clear and stable for many years and the individuals
concerned strongly desire a pubertal development that corresponds to the sex/
gender they actually feel themselves to be. It is important for transsexual ado-
lescents to develop in a similar way to their peers – so indeed already at thirteen
or fourteen. Otherwise, an unequal situation of development arises: the risk of
social exclusion increases. Further surgical measures are as a rule recommended
for an age after eighteen. There are, however, individual persons who were op-
erated already at sixteen, with mastectomies as well as feminizing surgery being
performed.
Performing hormone treatment
What guidelines do we observe at our centre regarding the start of a puberty-sup-
pressing hormone treatment?
Ň A gender expert recommends such a treatment.
Ň Puberty has set in and irreversible physical changes are to be expected.
Ň The patients have been living for some time already in the desired sex/
gender and are receiving psychotherapeutic support.
Ň The parents agree with the treatment.
How do we carry out such a therapy in practice? The adolescents are given GnRH
analogues. These are in fact endogenous hormones (of the hypothalamus) that
are reconstructed by pharma companies. They block the hypophysis and prevent
the release of gonadotropins, the hormones that stimulate the testes and ovaries
to produce sex-related hormones. This treatment is therefore very effective in
suppressing puberty. In general, we use the drug Trenantone® (with the active
agent leuprorelin acetate) that only needs to be injected subcutaneously every
three months. Treatment is rather expensive; one single injection costs around
450 Euros. The costs are fortunately covered by insurance, at least in Germany.
In transsexual girls who have progressed relatively far in their pubertal devel-
opment, we usually use cyproteronacetate (Androcur®); surprisingly very low
dosages of 5 to 15 mg per day are already sufficient to counteract a masculiniza-
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193
tion. In biological women who live as boys it is also possible to very effectively
suppress the menstrual cycle with a gestagen (Oragametil®).
When is the right time to begin a cross-sex hormone therapy? The adoles-
cents have already lived for some time in the desired sex/gender. In most cases
they can’t wait to get started with a cross-sex hormone treatment. For my first
patient we still involved the ethics commission of the university clinic Hamburg
which, after a hearing, delivered a favourable vote. The parents’ consent is of
course also necessary, since we are dealing with juveniles. In order to initiate
cross-sex hormone treatment we require assessments by two different gender
experts, even though almost all of our patients are presented in cooperation with
the Department of Child and Adolescent Psychiatry at the University Medical
Centre Hamburg-Eppendorf.
In most cases, cross-sex hormone treatment has been preceded by puberty
suppression for 6 months or a whole year. At this point the adolescents are al-
ready living in the desired sex/gender, have informed their surroundings about
the situation and are accepted as they are. Fortunately the majority of them re-
port a favourable acceptance after coming out, teachers and co-students usually
react with understanding. Some of the schools make an effort to add the desired
name in brackets and the new name already appears also on the class roster.
Changing rooms, physical education (PE) and the use of toilets are usually no
longer an issue. Of course there are also schools where transsexual students are
not treated so compassionately.
How do we then in practice go about such a cross-sex hormone treatment?
In transsexual boys we begin with the administration of testosterone, with the
dosage slightly depending on the bone age and body height. If I were to start with
a lot of testosterone in somebody who is small, I would reduce the final body
height. Exactly the opposite is true for transsexual girls: if I wait too long with a
cross-sex hormone therapy these transsexual women will tend to become taller.
That is why I frequently increase the estrogen doses faster, in order to arrive at a
final height that conforms to the desired sex/gender. In transsexual girls we use
estradiol valerate. In boys, testosterone undecanoate (Nebido®)intramuscularly
is very effective in causing virilization. As soon as the Testosterone treatment is
started the GnRH analogue can be discontinued.
Difficult decisions
Many parents are afraid of making a mistake when consenting to a hormone
treatment and think it better to let nature run its course. This is not an alter-
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native because non-intervention can cause these adolescents to be caught up
in a negative vortex, particularly in psychological respect. My colleague Co-
hen-Kettenis (2008) already mentioned above has expressed this very clearly:
“Non-intervention is not a neutral option.” I myself have experienced many very
impressive cases of how hormone therapy helped these young people to regain
their balance, how their performance at school improved and how they again
managed to establish positive social contacts. With the help of hormone treat-
ment the physical changes take place in a similar period of time as in members
of the peer group and the adolescents are not forced to wait in an extra neuter
category until all the others have already become either men or women. In my
view, aligning physically with the peer group is very important, for otherwise
transsexual adolescents are frequently relegated to a corner, very unhappy, even
though partly accepted or tolerated. The hormone treatment not only bolsters
their confidence and promotes their general psychosocial development, but also
facilitates the development of romantic relationships.
What are the long-term side effects of such a hormone treatment? As yet, not
many long-term studies exist, but the risks seem to be manageable. For instance,
the risk of breast cancer in transsexual women is even lower in comparison to
that of biological women and thus constitutes an increased risk compared to that
of breast cancer in biological men. In connection with hormone treatment we
also discuss with the adolescents the prospect of infertility. And at this juncture
I would like to report about a 17-year-old transsexual girl who six months after
beginning cross-sex hormone treatment decided to discontinue everything for 6
months, only to have her sperm cells frozen in case she should wish to have a
child later in life. I was very impressed that someone who shortly before a sex/
gender reassignment surgery – which has since then taken place – should want
to keep this option open for herself. She also has quite specific ideas about one
day having a child of her own, either with the help of a Lesbian couple, where
here sperm cells can be activated, or through a surrogate mother.
CONCLUSION
An early hormone treatment usually yields a significantly better result for the
body to align itself with the desired sex/gender than if one waits longer, allowing
the body to develop in the wrong direction. From my experience, it is extremely
agonizing for many of the young people concerned if they are expected to un-
dergo this pubertal development which they themselves perceive as dreadful.
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pubertal development should be completed before being allowed to begin with
hormone treatment. Of course, for young people only at the onset of puberty it is
almost impossible to assess how life will be as an adult. Sexuality, too, is usually
still quite an abstract notion for them. We are able to change these young people
physically in the desired direction, but in the process they do not automatically
learn everything that belongs to being a woman or a man. I regard myself as
someone giving advice and support to these adolescents, someone who also ad-
dresses the issue of sexuality and supports them in dealing with their body and
their emotions. Debate continues over the question whether an early hormone
treatment iatrogenously cements and fixates a certain development, thereby pos-
sibly preventing a homosexual development. A few years ago, when hormonal
treatment options did not yet exist, a person with a sex/gender identity disor-
der would almost perforce have tended towards a homosexual orientation – as
a feminine homosexual man or as a masculine lesbian woman. For this reason
a certain doubt always lingers with us who administer the treatment that there
could be a mistake in the assessment and that we are changing the fate of a
human life with our therapy. I am aware of this great responsibility and at the
same time prepared to take on the risk of this interference with nature, because
I experience almost on a daily basis that most of the young people concerned
are quite clearly happier with themselves and their lives thanks to my treatment.
REFERENCES
Cohen-Kettenis, P. T. et al. (2008): The Treatment of Adolescent Transsexuals:
Changing Insights. In: J Sex Med 5, pp. 1892-1897.
Hare, L. et al. (2008): Androgen Receptor Repeat Length Polymorphism Asso-
ciated with Male-to-Female Transsexualism. In: Biol Psychiatry 65, 1, pp. 93-96.
doi: 10.1016/j.biopsych.2008.08.033.
Korte, A. u.a. (2008): Geschlechtsidentitätsstörungen im Kindes- und Jugend-
alter. In: Deutsches Ärzteblatt 105, 48, pp. 834-841. doi: 10.3238/arzte bl.2008.0834.
Möller, B., Schreiner, H., Romer, G. (2009): Geschlechtsidentitätsstörungen im
Kindes- und Jugendalter. In: Z Sexualforsch 22, pp. 1-28.
Hormone Treatment of Transsexual Adolescents
For this reason I have difficulty in understanding those critics who demand that

196 Achim Wüsthof
Zhou, J. N. et al. (1995): A sex difference in the human brain and its relation to
transsexuality. In: Nature 378, pp. 68-70. doi: 10.1038/378068a0.
Steensma, T. et al. (2011): Disisting and persisting gender dysphoria after child-
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