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Treatment of Young MTF Transsexuals


Media interest in young transsexuals has always been high, leading to an uncomfortable feeling of possible exploitation in a few cases
.

Introduction
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 in to society as a female, this alone is enough to differentiate them from the experience of most transsexual women who transition when an adult.

It is also perhaps necessary to distinguish between intersex infants, who in some cases are assigned a gender contrary to their genetic sex, and children with a Gender Identity Disorder (GID, aka transsexual).  While very young intersex infants have no say in their sex assignment or reassignment (which is usually done before they are 24 months old), transsexual children consciously reject the gender in which they are being brought up at some point between two years old and puberty.

Prevalence
Since the 1960's - when Dr John Money, a physician at Johns Hopkins University, made the medical community at last recognise transsexuality - there has been an ever increasing incidence of Male-to-Female (MFT) of reported GID cases and requests for treatment across all age groups. 

No one compiles official statistics on transgender children, but an often quoted statistic is that 1 in 10,000 children have GID, this number seems to date to a study in the 1970's and vastly understates the current situation. Sources such as the internet and TV documentaries mean that children and parents are no longer accepting as gospel the advice of an experienced and over-loaded doctor or psychiatrist.  In recent years the growth in reported GID cases among teenagers, particularly boys, has been extraordinary.  For example in 1999 alone, the number of transgendered people under 22 in the "gender reassignment" program at New York's Michael Callen-Audre Lorde Community Health Center tripled! 

In 1997 there was an estimated 600 transitioned transsexual children (usually defined as under 18) in the UK, just a few years earlier the acknowledged figure would have been a handful.  Note:  The figure of 600 excludes the very small proportion of "XY" intersex children born in the UK with ambiguous or malformed genitals who are assigned to the female gender by doctors while still a baby, perhaps 20-40 each year deriving from USA figures.  There are also many children with "male" genes who are identified at birth as female and then brought up as girls, for example there are perhaps 3000 "XY" women in the UK who were born with Androgen Insensitivity Syndrome. 


Jackie Green had sex re-assignment surgery in 2010 - on her 16th birthday.  Her high profile in the UK media has encouraged many other children with GID to come forward.

A new study published in November 2005 suggested that there were 2000 young transsexuals in the UK age 15-19 (about 1 in 2,500 of that age group) - although with no further definition of their status.  The exponential growth seems be continuing, one UK clinic reported that they had 97 young GID referrals in 2010, 139 in 2011, and 165 in just the first two months of 2012 alone!

Undoubtedly this growth is largely 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 long before they reach the critical point of puberty.  Many children with GID problems learn about transsexualism from TV shows and documentaries and then go on-line, 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, MTF children who in the past would have suppressed their female gender, or at least defer dealing with it openly until reaching adulthood, are now coming forward while still a child.   In most cases their families respond very 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. 


Born in 1992, German teenager Kim Petras (formerly Tim) became world famous as supposedly the youngest person ever to have had SRS - at age 16.  Although that claim is incorrect, her exuberant femininity has made her an icon for young transsexuals.

Unfortunately there continues to be reluctance by the medical profession to pro-actively treat gender identity disordered children, even when they are diagnosed as "core" or "true" transsexuals.  

While recent trends are somewhat encouraging, young transsexuals (under 20) 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 transgirls tend to immediately go stealth after transition, and the girls pictured on this page are exceptionally brave about their transsexuality - or had little choice as they were out'ed by the media.


Willem, age 12 and Kristel (born Jeremy) age 11, for more information see Lynn Conway's site.

Sex Assignment 
A persons sex can be determined or judged by many factors, including:

  1. Legal Sex:  In the UK the infamous ruling by Lord Justice Ormrod, irreversibly 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 type testosterone plasma levels, or female type oestrogen and progesterone plasma levels.
  3. Chromosomal Sex:  Male "XY" or female "XX" genes as determined by a karyotypic study (in rare cases there are other combinations.
  4. Internal Sexual and Accessory Organs:  The presence of male (testes) or female (ovaries) gonads, and male (e.g. vasa 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".
  7. Sexual Identity:  The sex a person identifies with and believes they actually are.  


Maxine (born Maksim) transitioned at age 14, had a "nose job" at 16, started hormones at 17, had SRS at 20 and is shown age 21 in the main picture. (Moldavia / Germany).

It is quite possible for these factors to disagree and contradict, e.g. a post-operative transsexual person may well have a male birth certificate, a male karyoptype (XY genes), no internal female sex organs but female appearing genitalia and sexual characteristics, live as a woman and believe that she is a woman.

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 Re-Assignment Surgery"  (GRS).  It's essential to differentiate between a person's physiological sex (factors 4 and 5), and a person's social & mental gender (factors 6 and 7), surgery can't ever change the later and phrase "Sex Re-Assignment Surgery" (SRS) 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.   


Three theories of gender development (click to enlarge)

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 intersex children raised as one sex eventually migrate back to the gender that their genetics or their prenatal hormonal environment would have predicted.

joan.jpg (11388 bytes)
John/Joan (David Reimer) - may he RIP.

Bill Summers, a professor of medical history at Yale who has 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 this 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 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 a young child decides 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.  


A staged but still beautiful photo of a young Swedish transgirl.

Sexual Identification of Transsexual Children
It is important to note that many boy-to-girl "transsexual's" do not consider themselves to be transsexual - indeed they often actively dislike being called such - they just consider themselves to be girls and in a medical context suffer from Gender Identity Disorder (GID).   The reality is that young transgirls often associate the word "transsexual" with TV documentaries featuring strange balding middle-aged men, married with children, who at the end of the programme still look, sound and behave like men wearing wigs, dresses and too much makeup to their very discriminating eyes and standards.  Young transgirls simply cannot relate themselves with these examples of transsexuality - their problems are totally different, and even passing is rarely one of them.

Zach Avery, age 5

Whilst there is no such thing as the typical young child with GID, perhaps a good example is Zach Avery.  At first he seemed to be a 'normal boy' but when age 3 he turned around and told his mother, Theresa, "Mummy, I'm a girl".  She assumed that he was just going through a phase and just left it at that, but Zach started to insist on wearing his sister's clothes and would become upset if anyone referred to him as a boy.  Theresa notes that "He used to cry and try to cut off his willy out of frustration".  His parents became increasingly worried by Zach's behaviour and took him to the doctors.  After numerous consultations and observations, he was officially diagnosed by NHS specialists as having GID, and transitioned age 4.

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.  This has been confirmed by numerous studies...


The age of realisation of gender variance

In one study, two thirds of transsexual boys were aware that they belonged to the opposite sex and exhibited such behaviour by age 5, and 77% by age 10. 

Another study of 137 MTF transsexuals, 70% exhibited cross-gender behaviour before age 10, and another 20% before age 15. 

A third study of 121 transgender individuals between age 18 and 65+ gives a modal average of 5 years for the age when the participants began to question their assigned gender, and a mean average of 7.9 years.   Just 4% first had doubts about their gender after age 18.  Over 80% of the participants in the studywere assigned male at birth.


Riley (formerly Richard) "Grant", age ten, she has never doubted that she is a girl and transitioned when age 7. (USA)  Source: Heidi Gutman/ABC

Most young transsexuals suppress their doubts, as one later said "my overriding need was to a keep it a secret".  But a few - perhaps 1 in 20 - do come out and seek acceptance that "God has made a mistake".

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 7 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 (SRS). 
  

Jerke, a 10-year old transgirl
from Holland.

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

  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.  

Nicole Roukema
Nicole Roukema (Netherlands) was born Neils but knew that she was a girl by age 3.  She had transitioned by age 13 and plans to have SRS surgery when 18.

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 1970's and 1980's (indeed, perhaps too common) - but has since become discredited and unfortunately there has been a carry-over affecting young transsexuals.  It seems too often require courageous and forceful parents before doctors will medically facilitate the transition of a minor.


Suzannah Fleming, age 6 (inset) and now.  She started hormones age 12 with the brave assistance of her mother - a registered nurse.

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 transgirls.  On the other hand, things do seem to be improving and television and the Internet is playing a key role in this - these days most transsexual children first learn about "transsexuality" from TV programmes, relating to this condition they - and often their parents - seek further information via the Internet (now an extraordinarily valuable resource) and from books.


Danielle (formally Daniel) Gomez (Mexico/USA) had SRS at age 17, while still at High school.  Her supportive mother has written a book about Danielle's journey to womanhood.

It is impossible to underestimate how important the understanding and support of parents is for a young transsexual her eventual success in life.  It is also difficult to underestimate how much emotional strain having a transsexual child can impose on his/her 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 they can go to a different school and avoid anyone who knew them as a boy. 

In another positive example, Jamie never felt herself to be a boy, and when at age 11 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.


20 year old Rachel transitioned when 17, but still visits her parents as their son Daniel. (UK)

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 17: "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."

 newyork.jpg (12872 bytes)
Now finally transitioned, for many years Amy (shown age 19) received psychiatric treatment to "cure" her gender dysphoria.

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 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 in to 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 also 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 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 worry.  
 


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


Breaking all
the guidelines Marilia (formerly Errolclaud) Gabriela started hormones at age 13.  She had SRS at 22. (Brazil).

Medical Guidelines for the Treatment of Transexual Children
The widely followed HBIGDA Standards of Care of Gender Identity Disorders, a document which has previously (and increasingly controversially) been against the treatment against the hormonal treatment of under 16's, has relaxed its rules somewhat in the latest (2001) Version 6.  It now states that:

"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 11 for biologic females, age 12 for biologic males]  .....

"Adolescents may be eligible to begin masculinizing or feminizing hormone therapy as early as age 16, preferably with parental consent. In many countries 16-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 18 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 feminizing hormone treatment at a normal puberty age and delaying any sex change surgery until at least age 18, 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-16 MTF school girl.

In its defence, the "Standards of Care" is clearly and understandably concerned about some instances of unsuccessful boy-to-girl gender re-assignment of intersex babies, such as the highly publicised failure of the gender re-assignment David Reimer (aka the "John/Joan" case), and wants to avoid any future repetition.

ali.jpg (9235 bytes) Ali (formerly Alistair)  Gregory at age 16 in 1999, when still denied feminising hormones. (UK)

Importance of Early Treatment
Unfortunately, because of the John/Joan case, and mistakes made in the past when dealing with intersex children, recent medical studies have tended to emphasise the minority (about one quarter) of gender disordered children who don't eventually have SRS, and the disadvantages of early gender and sex-role re-assignment.  In particular, many advice against early genital surgery or irreversible feminising hormonal treatment.  But they neglect to consider why so many young transsexuals eventually have SRS despite the immense "corrective" pressures often exerted on them, nor do they consider whether those that don't have SRS would have perhaps enjoyed their lives more as a woman than they now are as a man. 


Campbell, shown age 16, was born a boy but always considered herself a girl.  She received no early medical treatment and is now facing the results of an unwanted male (rather than female) puberty .

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's indisputable that the earliest possible transition and pre-puberty hormonal and surgical treatment will offer most boy-to-girl's massive psychological and physical benefits.  


Jonas and Nicole Wyatt (USA)

A rare clear example of the results of early medical treatment is Wyatt and Jonas Maines.  They were born identical twins, but from a early age Wyatt rejected being a boy.  His parents were very supportive, and at age 11 the twins became brother and sister when Wyatt transitioned  and changed her name to Nicole.  The family sought medical help from the Children’s Hospital Gender Management Services Clinic in Boston, USA.  The clinic prescribed Nicole with puberty blockers and female hormone injections.  The dramatic effect of this treatment is shown by the fact that at age 14 Jonas (in mid-male puberty) was 167 cm tall ( 5ft 6 inches) and weighed a 52 kg (115 pounds), whilst Nicole was still a petite 155cm (5ft 1inch) and weighed only 45kg (100 pounds).

Young boy-to-girl transsexuals have no doubts about their female gender - and early medical treatment can help them easily pass as a girl.

Early transition and commencement of treatment 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's an absolutely priceless experience if a transsexual girl goes through her adolescence and growing-up 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 photo's to show her future boyfriends.  For many girls, denying these experiences to her and enforcing an unwanted male gender is simply a disaster.

 

Monica
, now in her mid-20's.

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."

Monica was born a boy named Morten, but always rejected being assigned as male.  By her teens, her parents were worried that she was becoming suicidal and supported her transition.  She finally had full SRS at age 22. 

Now 45, Anna Taylor  transitioned at 11 and began hormones at 13 after finding a doctor in Amsterdam willing to prescribe them.  Surgeons refused to perform her SRS until she was 18, she  had it 3 days later. (UK)

Anna ran away from home several times until, aged 8, she went to live with her grandparents who were prepared to bring her up as a girl.  At age 11, 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 13, 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 18."


Jasmijn age 9 (born as Colin).  During a summer vacation her family chose her new name. (UK)

A recent follow-up study of sex-reassignment in 22 adolescent transsexuals (ten started hormones under age 16, twelve under 18) found that post-operatively 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 decision 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 full conquered, while an appropriate puberty offers a greatly eased path to a gender reassignment, both physically and psychologically.  
 

Laureen (formally James) Harries, age 27.  She transitioned when 19 and had SRS at 22.  She was a minor TV celebrity in the UK and is shown inset when 14.  Her life story is atypical for a young transsexual. (UK)

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 developing.  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 the school, because they can concentrate on nothing, and some have suicidal thoughts."


Lauren Foster nee Shipton.  She had SRS at age 18 and became a model and actress; she's now married (South Africa / USA)

When - at age 10 - Riley (who had been living as a girl since age 7) was warned by her mother that nature would soon start turning her in a man, her reaction was a 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 jealously of girls and their physical changes, by age 15 some 90% 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. 


Kelly at the start of her transition. (UK)

One now happily post-SRS girl described how she felt at puberty: "That was the hardest.  My own body was staging a mutiny, even."  At 16 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 masculinize on and on.  And so at 17 I graduated from high school and found hormones on the street."

Now 21, Zoe concurs about puberty: "When puberty arrived I was repulsed by my erections and deepening voice.  At times I felt suicidal."  Jamie Cooper was 12 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 16 before receiving hormone treatment - she transitioned on her 16th birthday.

 
How hormones affect a girls body during puberty (click graphic for large version)

A lot more information about puberty and its effects is given in the separate article here.
 
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. 
 


Oestrogen levels in Women


Testosterone levels in Men

The changes in hormone levels at puberty are dramatically different between boys
and girls, unsurprisingly this results in dramatically different physical changes.

Professor Cohen's policy is that if it appears that the gender dysphoria feelings are becoming stronger then they should be prescribed puberty blockers to temporarily halt puberty until they are 16.  When they are 16, 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 8-9 years.  Before the onset of male puberty (at about age 11, but can vary ±2 years) a bilateral orchiectomy (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.  


Nina (formerly Guido) transitioned at age 11.  She's is pictured nearly 3 years later, age 13. (Netherlands)

When an orchiectomy 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 11 and 17 (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 17 - Jenny Hiloudaki, Tula, Hari-su, Roberta Close, Dana International, etc. 

 
Vicky Nicole Eriksson (born Victor) age 18.  She terms herself a model and transgender activist.  (Sweden)

A typical example is Nicole Vicky Eriksson, born in 1995 in the small village of Stråtjära, in Hälsingland, Sweden. She was christened Victor, but always knew that she was a girl trapped in the body of a boy - when asked age 3 what he wanted to be when grown up, she responded "A woman!".  Her family and the people of her home village accepted her transgenderism, and she began taking hormones at the age of 16 years, with her sex change operation planned in 2013, when she reached 18.  She moved to Stockholm to study fashion and dreams of a career as a model - her ImVicky blog already has a huge following.

Ashlyn Parram (born Lewis) was not allowed to sit an exam at her school because she was wearing a girls uniform, including skirt.  The headmaster only relented after being shown the Equality Act 2010.  Shown age 11 and 16. (UK)

Doctors certainly seem to agree that giving - for example - a 13-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 hormone 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 feminizing hormonal treatment until the girl is at least age 16) 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 male type puberty with its physical effects, and Dutch studies have recently confirmed the effectiveness of such treatment. 


Young transsexuals such as Kelly benefit enormously from blockers and early use of female hormones, but some fundamental physical aspects remain. (UK) 

Unfortunately GnRH analogues are expensive drugs, but they are to be much preferred in 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.  Riley (pictured right, age 9) was when 12 diagnosed both oestrogen and testosterone blockers.  It was explained to her that this would make her body more feminine, her voice won't deepen and that she could eventually 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 transsexual may have achieved in Germany when it was revealed in 2007 that doctors had prescribed puberty blocking and later female hormones to a 12 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 to his hair cut and wanted to cut of his "thing", for the sake of a normal life his parents increasingly accepted their son Tim as being their daughter Kim.


Kim Petras age 13.  Born in August 1992, in 2008 she became famous as the world's youngest post-SRS transsexual at age 16. (Germany)

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 dress 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 growing facial hair and her voice 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." 


A transgender group meeting at a university - in recent years "Transgendered" has finally been added to Gay, Lesbian & Bisexual.

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 17 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".


Kim Petras, age 21

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 12, and by age 14 was fully transitioned and living as a girl - with her identity and medical insurance cards changed to her new name and female sex.  German law only permits sex-assignment surgery (SRS) at age 18, but Kim apparently had this in November 2008 - just two months after her 16th birthday.  This created headlines around the world that proclaimed her to be the youngest person to ever have had SRS, although that claim is false - even excluding XY intersex children.  Just two examples are the sad case of David Reimer (age 22 months), and Victoria Beltran whose parents managed to get her surgery when just 15.  Also, hundreds of SRS procedures are performed every year on under-18's in Asia and South America, and it seems very likely that some are under 16.

Kim handled the intense media interests surrounding her surgery with great honesty and confidence, for example she told one interviewer "I was asked if I feel like a woman now - but the truth is I have always felt like a woman - I just ended up in the wrong body." Since age 18, Kim has concentrated on developing her a career as a singer.

 


Angel (formerly Oliver) Wheadon began taking her Mum's HRT pills at 9, transitioned at 12 (shown left at 13), was officially prescribed oestrogen hormones at 14, had  SRS at 17, and is shown right age 21. (UK)

Effects of Early Hormonal Treatment
A
doctor now treating transwomen says: "I began working with transgendered people in their 20s. The people in their 20s were socially in good shape. But they were having trouble getting their physique to conform to their identity. I knew the twenty-somethings could have better chances of passing if they were treated earlier."

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. 

 

Amanda Lear (France/ UK/...) may have started hormones at 15 - depending what birth date you accept.

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 12, but plus or minus 2 years) than after a male puberty has completed (on average 17, plus or minus).  This is a severe problem given the great reluctance to doctors to assist transsexual patients under age 18.  Incidentally, the anticipated and achievable benefits from starting female hormones decline rapidly in the decade after puberty ends. 


A holiday snap from a 19 year MTF taking oestrogen and transitioning. (UK)

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 dose hormone therapy intended to initiate a full female type can be safely started by age 11, although it in practice it is often deferred to 12 or even later, particularly if the individuals 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 9 - an age at which many girls begin to notice some initial puberty changes, in particular the development of breast buds. 


Ashley transitioned in her late teens - just young enough for 18 months on oestrogen hormones to have a dramatic effect. (USA)

As indicated already, surgeons have become very reluctant in recent years to perform a bilateral orchiectomy on even young intersex patients, let alone gender dysphoric boys; however failure to do so does accept the slight risk that even suppressed testes might still 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.


After legal debate Johanna (formally Johannes) Bulow (Germany) was allowed puberty blocking drugs at age 12 and female hormones at 13.  She's shown age 14, and (inset) age 15 holding her new identity papers.

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 intersex rather than transsexual) taking hormone replacement therapy (HRT) following early orchiectomy.  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 effect on the skeleton - reducing male type rugged'isation and enhancing female type features, for example slightly broadening the pelvis and helping reduce the girls adult height (by perhaps an inch or two) compared with if she had experienced a male puberty.  However, while hormones play an important role in post-pubertal body shape, 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 a degree of skeletal masculinisation, even if she commences female hormone treatment at 11 or 12.  In general, her physical characteristics as determined by her skeleton (height, skull, hand & feet size) will lie between the male and female norms post-puberty - although more towards the former than the later.  This 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 (67½" vs. 64¼") and have long legs - both absolutely (32½" vs. 30") and relative for her height, ideal for those girls with ambitions as a model!  [For more information about average male and female body sizes, see the article on this site]


"
Lucy Parker is a typical teenage girl, obsessed with clothes, boys, make-up and shopping.
 Lucy (formerly Richard) transitioned at 16 and a BBC documentary followed her having breast augmentation just days after her 18th birthday allowed this. (UK)

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 endocrinologists sometimes prescribe large doses of oestrogen (usually Ethinyl Estradiol) 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 of 61 - 67". 

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") appears likely. 


Thalita Zampirolli began hormones age 15 and had SRS on her 18th birthday. She also has had 260g silicone breast implants.  Shown age 24. (Brazil) 

The following table compares the effects of beginning female hormone treatment before a male puberty starts (which is typically age 12), with beginning treatment after male puberty has completed (i.e. after about age 17).  Extensive experience with intersex but "XY" female individuals indicates that for the very best results, low-level oestrogen treatment should be started at age 9, and stepped up to "puberty" levels at 12.

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

Desired Characteristic

Pre-Puberty Hormone Treatment

Post-Puberty Hormone Treatment (Note 1)

Prevent skeletal masculinisation, e.g. large hands & feet; square jaw

Some benefit
(e.g. growth may terminate earlier, less heavy bones)

No

Relatively lower height

Yes (note 4)

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 
(Note 2)

Yes

Some reduction

Female type subcutaneous fat deposits and body contours (Note 2)

Yes

Variable redistribution. Increased fat deposits most significant on hips, buttocks & thighs after prolonged treatment

Reduced weight  (Note 2) No

May actually increase unless supported by dieting and exercise.

Small waist

Some benefit

May actually increase unless supported by dieting and exercise.

Full and mature "Tanner V" breast development  
(Note 3)

Substantial benefit
Breast development 1 or 2 cup sizes less than mother / sisters

Variable from slight to substantial breast development, Tanner V very unlikely. 

Notes:
1.  Effects of hormone treatment vary considerably by individual, and can take 2 to 5 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.  E.g. results are considerably more dramatic with an 18 year old than a 28 year old, but not usually very different between a 38 year old and a 48 year old.  Other treatments can help feminise some characteristics in adult transsexuals.

2. Oestrogen hormones tend to deposit fat.  Sensible dieting and suitable exercising (e.g. aerobics, not power lifting!) will 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 (WHR) of 0.7-0.8, a range which is a key visual "female indicator". 

3.  Breast development will vary considerably depending on the individual's 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 girl's mother and sisters.

4.  Dr Stoker of the Boston Children claims that without hormone treatment a transgendered girl from the UK would have ended up being been 6ft 4in tall, rather than an acceptable 5ft 10in. Excessive early oestrogen intake can actually result in stunted growth and below average female height.

(Right, 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.)

 

Model and actress Pascale Ourbih  transitioned when she moved to Paris, age 18, and had surgery soon afterwards. (Algeria)

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 in to that of a man.  The end of puberty is a fundamental and irreversible physical marker, from which the plausible effects of feminizing hormonal treatments on the body of a transgirl/woman decline with depressingly rapid speed.  For any transsexual woman starting treatment when already physically mature (and this merely means age 20 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.


Wendy (UK) at age 17, when doctors would not prescribe her hormones despite her parents full support for her transition.

Hormone Regimen's in Transsexual Girls
There seems to have been little published research with regard to the dosage for hormones in young transsexual patients, however research which relates primarily to Androgen Insensitivity Syndrome (AIS) patients is also probably applicable to transsexual girls.  Zachmann et al cite one AIS patient who had undergone orchiectomy in whom oestrogen administration was started at the earliest estimated pubertal age of 10.3 years in the form of Premarin 0.625 mg 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 - 0.01 mg ethinyloestradiol 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 11 years and should not be delayed in the hope of achieving a greater mature height.  Batch et al suggest a regime of 5 micrograms of ethinyloestradiol daily for the first 6 months, increasing to 20 micrograms daily by the end of puberty.

 

Katie (USA), shown
age 16 and while still in High School.  She transitioned when age 10 and her parents fought for her right to attend school as a girl.  Although on female hormones for many years, she was still waiting for her SRS in early 2003, now 19.

Soule et al. suggest that the best course of action may be to perform a orchiectomy just before puberty (at 11 years in a case quoted) followed by oestrogen therapy (ethinyloestradiol 2 micrograms daily, gradually increasing to 20 micrograms over 2 years, in the case quoted) 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. 

However, oestrogen levels are higher in XX girls than in XY boys, even in childhood.  XX girls start producing oestrogen at 8 or 9 (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.  Dr. Stanhope suggests 1 microgram ethinyloestradiol per day from age 8-9, with an increase at about 11-12 years.
 


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

Females Hormones and Attractiveness
A very awkward problem for psychologists advocating delayed hormonal treatment for young transgirls is that as result they will be physically less attractive as a woman to men.

There is a strong and direct correlation between 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 skin’s appearance during the average seven-year-long puberty.  Miriam Law Smith of the University of St Andrews states the hormone has a hormone has a crucial role in determining facial appearance, giving 13-year-olds doses of oestrogen will "certainly may 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 6 feet) may according to one study subsequently suffer from lower fertility. 
 


Kelly van de Veer (Netherlands) had SRS at age 19 

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. 


14 year old Jamie (left) and 15 year old Danique are unambiguously girls after their transition. (Netherlands)

About 95% of natal "XX" women consider themselves as being heterosexual.  In comparison, studies of the sexual orientation of post-SRS 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 30's or even 40's), and are almost certainly not representative of the relatively few young transsexuals who transition before the completion their male puberty.  It is very likely that when compared to older transwomen, a far higher percentage of young transsexual women identify themselves as heterosexual and attracted to men.  Indeed, for under 21's, 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.


Roberta Close started hormones at age 16.  Even as an undis-covered teenager, her attraction to and success with men is undoubted. 
(Brazil)

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 16-year old transgirl 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 SRS for years yet.


Two sisters, Alina - in red - was previously a brother. (Russia).

Unlike older transsexual women - again - 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% 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.


Young transitioners rarely have the difficulty in passing faced by most over 20's.  A TS girl with a girl-girl friend. ... I will let you work out their genes! 

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 subtype of so-called "homosexual transsexuals" (that is, individuals who are, before SRS, 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, she feeling (unfortunately often correctly) that the relationship may not survive this becoming known.   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 out's herself, she often soon regrets it - and for good reasons.


These young transsexual women featured in the July 2002 edition of the UK magazine Marie Claire.  Nina (second from left) was 22, Jamie (back, fourth from left) was 16, and Zoe (first from right) was 21.  Jamie eventually had her SRS just five days after her 18th birthday - as soon as the Standards of Care permitted and her surgeon could perform the operation.


These four long post-operative transsexual women (ages 23-27) from Thailand appeared in some editions of
Maria Claire in 2006, making an interesting contrast to the picture above.


Jenny Hiloudaki was born
Yiannis in 1981.  He began secretly taking female hormones when just 13, and had Sex Reassignment Surgery age 20.  She was 'outed' at age 29, but two years later voted 'Greek Woman of the Year'.

deborah.jpg (7472 bytes)
Deborah Davis had sex reassignment surgery at age 17, it is still very rare for teenager's to be able to have such surgery

 

Sex Re-assignment Surgery
After hormones and transition, the next and final step is sex-reassignment surgery.  Extra-ordinarily, only about 1% of SRS operations performed by western surgeons are on girls under age 20 (almost all of whom are 18 or 19).  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 16, 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-20 (or indeed under 25) surgery candidates compared with older candidates - the median average age of European transwomen at the time of their SRS is mid-to-late 30's, with a mean average age of around 40. 


Athena Javaher, shown age 20, had SRS when 18.  (Iran)

Angel Paris-Jordan (formally Oliver Whedan) had SRS and breast implants when just age 17. (UK) 

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 to 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 10 years. Many underwent surgeries of various kinds, on average in the twenties, with one undergoing SRS as early as 15 years".


Claire Farley.  The film Red Without Blue documents her transformation from Alex and her evolving relationship with her twin brother.

Clair (formerly Alex) Farley told her parents that she was gay in when 13.  After a suicide attempt age 15 she told a councillor "I feel that I should be a girl".  She finally transitioned at age 18 and began hormones, over the next year -s "My hips widened, my thighs thickened and tiny breasts started to appear".  She finally had her SRS at age 23, "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. 


The stories of young transsexuals are often very news worth.  Melanie McPryce (formerlyTom McGlone) transitioned at 16, started hormones at 17 and spent €22,000 to have sex-reassignment and breast augmentation surgery in Thailand the day after her 18th birthday. The 
News of the World newspaper gave her story a centre page spread and hopefully suitably recompensed Mel and her mum.

Supportive parents are undoubtedly influencing a 'system' and 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 increasingly 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 not female hormone therapy for those reaching their teens. 

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 5-year boy was allowed to enrol in kindergarten as a girl with a "gender-neutral name" in Florida, USA, having been diagnosed with gender identity dysphoria (GID) two years ago 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 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 11-12?

Meanwhile, in Japan a 7 year old boy with GID, Ryoko Kanda, has been allowed to enrol as a girl at a school is in the prefecture of Hyogo, about 270 miles west of Tokyo after being diagnosed with gender identity disorder at age 6.  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 at Tokyo Musashino Hospital, 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.

Progress since 2001
This article was first written in 2001, revisiting it a decade later there has been some progress in the treatment of young transsexuals.  There can be almost no doubt that a series of highly publicised transgender success stories - basically young boy-to-girls who thanks very substantially to early medical treatment look like and sound like teenage girls - have helped this immensely.

Just a few of the success stories, from the left Cadence, Larissa, Kim, Marti, Devon and Jackie

Little by little an increasing number of clinics are now helping young transsexuals with medication and even surgery at an early age.  Two examples:

USA: In 2007 the pediatric endocrinologist at the Children's Hospital Boston, Dr. Norman Spack, set up a clinic for pre-adolescent transgender children. Dr Spack uses drugs to delay the first stirrings of a youngsters' puberty, typically age 12 to 14 for a boy. The effects of these puberty-blocking drugs are reversible but is not the case with hormones. Dr Spack is flexible about the age he prescribes estrogen - i.e. he's not rigid that the child has to be age 16+, but will only do so after months of consultation with the patient and her parents.  He says "When kids take this step, they are rewriting their own future: The hormones have a powerful, pervasive effect, changing their height, breast development, and the pitch of their voices ... You have to explain to the patients that if they go ahead, they may not be able to have children. When you're talking to a 12-year-old, that's a heavy-duty conversation".


Matti, age 15

UK: In 2011 the Portman and Tavistock Clinic gender identity service was set in north London to provide treatment to transgender children under the age of 16.  It was initially deemed controversial due to the patients' ages - with critics arguing that the youngsters lacked the ability to consent to the therapies.  However in just 2 years the clinic received 142 referrals of children aged 11 to 15 from parents and carers.  Dr Polly Carmichael, director of the service, said it was "better for children not to have gone through puberty before transitioning". But she added: "You are asking someone aged as young as 11 to make big decisions about their adult life and identity. We have to be very careful to keep options open".

Perhaps the most important recent development is that the famous/notorious "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People" (which very few medical professionals will dare not to conform to) has now advanced a tiny bit as regards young transsexuals in its seventh edition, published in 2011.  It now allows the use of puberty-suppressing hormones - but only when puberty has already begun!  It also says that "Adolescents may be eligible to begin feminizing/masculinizing hormone therapy", essentially from age 16.
 


Elaine at her college graduation (USA)

Conclusion
There is no debate that for the best possible final outcome, the sex-reassignment treatment of a male-to-female boy/girl with GID 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-18 transgirl will identify totally with her new female gender and appearance, passing well both psychologically, socially and physically; and be far happier as a female and have no regrets.  She will still face problems of course, such as hiding her lack of periods and worrying about her inability to have a baby to a fiancée ... but these are a totally different set of problems from what a decades delay would have imposed upon her - such as an inability to pass due her beard, deep voice a bald patch, plus having a wife and two children.


Romy Haag, showgirl, singer, actress and muse of 70's popstar David Bowie had SRS at age 19. (Germany)

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 SRS 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 UK only one NHS 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 over 60 million people!  

Despite the improving situation - the transsexual who transitions while still under age 18 rather than older remains very much the exception rather than the rule.

Personal Examples
(Please contact me if you wish your details to be added)

Warning:  Some of the hormone regimes stated below seem to be excessively high, overdosing on hormones will not have any additional physical feminisation effects but does have very serious and dangerous health risks.  Hormones should only be prescribed and taken under qualified professional supervision.

Belinda Darlington
http://www.facebook.com/
profile.php?id=528701532

Born: ?
Hormone Regime: Began hormones age 14
Surgery: 
SRS (May 2001), Facial feminisation (2010)

 

Rachel Saunders
http://www.geocities.com/
  lightandbeauty/

Born: April 1982
Transitioned: Age 17
Hormone Regime: Began hormones Sept 2000.  Daily regime: 1.25 mg Premarin.
Surgery: None.

 

Anonymised Entry

Born: October 1982
Hormone regime: Began hormones age 18, initially 0.625 mg of Premarin per day & 5 mg of Proscar per day.  Premarin dose later increased to 2.5 mg daily. 
Surgery: Age 18  Orchiectomy (August 2001).

 

Kie
[Website off-line]

Born:  January 1975
Hormone regime: From age 16, Diane 35 & Progynon Depot/Proluton Depot hormone injections
Surgery: Age 18,  rhinoplasty; age 25, SRS, tracheal shave, breast augmentation (textured 280cc silicone gel implants, submusc., transaxillary incision)

Natta Klomklao
http://www.srs-thailand.com/
  nklomklao/

 
Born: July 1970
Hormone Regime: From age 11, Diane 35, from age 16, Premarin and 10mg estradiol valerate + 250mg hydroxyprogesterone-Caproate injections
Surgery: Age 16, SRS; age 17, rhinoplasty; age 18, tracheal shave; age 25, breast augmentation (280cc).

Anonymised Entry

Born: January 1977
Hormone Regime: From age 18, 2.5mg of Premarin and 50mg of Novo- Cyproterone per day
Surgery:  Age 24.

 

Jhenna Kelly Taylor
[Website off-line]
 
Born:
17 August 1981
Transitioned:
Age 16
Height:
169 cm; Weight 52kg
Hormone Regime:
From age 17, 100mg Androcur & Estradam
daily.
Surgery:
Age 21, SRS (November 2002).

Barbie
[Website off-line]

Born: 1983
Transitioned: Age 16
Hormone Regime: Began hormones at 17.  Current regime is twice monthly injections of 40 mg Estradiol Valerate and 150 mg Depo-Provera. 
Surgery: Plans to have SRS in 2003.

Anonymised Entry

Born:
October 1981
Transitioned: Age 15
Hormone Regime:
Began Premarin age 14.  Current regimen is 10mg Depo-Estradiol (estradiol cypionate)  biweekly intramuscularly.
Surgery: SRS planned mid-2005

Kelly van der Veer
http://www.bigkelly.com

Born: 6 May 1980
Transitioned: Age 16
Height: 186 cm
Hormone Regime:
Began hormones at age 17
Surgery: Age 19, SRS (February 2000)

Nun Umdomsak
http://srs-thailand.com/nudomsak/

Born:  11 June 1980
Hormone regime:
From age 13, Diane 35 tablet & 1.25mg Premarin daily; age 15 10mg Progynon Depot & 250mg Prolution Depot combined injection.
Surgery: Age 18, rhinoplasty, thyroid cartilage reduction, silicone injections to chin and cheeks, chin implant; age 19, breast augmentation; age 20 SRS (Oct. 2000)

Jordana
http://www.vh1.com/artists/az/
   1_8_7/bio.jhtml

Born: 1977
Height: 173 cm; Weight 54kg
Hormone Regime:
Began hormones age 15, 2.5 mg Premarin & 100mg Spironolactone daily.  Later Estrace, Androcur daily and Estinyl injections monthly.
Surgery: Age 21, SRS

Anonymised Entry

Born:
19 January 1987
Height: 173 cm; Weight 61kg
Hormone Regime:
  Began hormones age 17 - 3.75 mg Premarin and 200 mg Spironolactone daily
Surgery: Age 18, SRS and tracheal shave

Anonymised Entry

Born:
1986
Height: 168 cm; Weight 55kg
Hormone Regime:
  8 mg Estrofem, 0.5 mg Dutasteride 200 mg and Spirolacatone 200 mg daily. Microgest first 10 days of the month
Surgery: Age 21, breast augmentation
Vanessa Lopez
http://es-es.facebook.com/people/Vanessa-Lopez/772304486

Born: 6 December 1982
Height: 175 cm; Weight: 59 kg
Hormone Regime:
  Testosterone blockers age 17.  Began hormones age 18 - Premarin.  Currently 1 mg Androcur every second day.
Surgery: Age 20, SRS

Jamie Sullivan
http://www.youtube.com/
jamielivefree

Born: 1988
Transitioned: Age 21
Height:  178 cm; Weight: 64 kg
Hormone Regime: Began hormones age 19 - 300 mg Spironolactone and 6 mg estrodiol daily,
5mg medroxyprogesterone on a monthly cycle
Surgery: Age 22, facial feminization

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

More contributions and information are very welcome, and your identity will remain confidential unless you say otherwise.  For this page I'm particularly interested to hear from any girls who transitioned or started hormonal treatment by age 18, and had SRS by 21.
  


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Copyright (c) 2011, Annie Richards
Last updated: 29 November, 2011