Treatment for trans kids can start younger, according to new guidelines – WSB-TV Channel 2

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A leading transgender health association has lowered its recommended minimum age to start gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, around a year earlier than the advice previous ones. The group acknowledged the potential risks, but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of its publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 physicians, social scientists and others involved with transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment for adolescents whose gender identity does not match their assigned sex at the birth, the group said. This evidence is limited but has increased over the past decade, the group said, with studies suggesting treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical changes at puberty around the same time as other teens, said Dr. Eli Coleman, group standards of care president and director of the Human Sexuality Program at the University of Minnesota Medical School.

But he stressed that age is only one factor to weigh. Emotional maturity, parental consent, long-standing sexual discomfort, and careful psychological evaluation are among the others.

“There are definitely teenagers who don’t have the emotional or cognitive maturity to make an informed decision,” he said. “That’s why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but advice for adolescents is sure to get more attention. It comes amid a rise in the number of children being referred to clinics offering transgender medical treatment, as well as new efforts to prevent or restrict treatment.

Many experts say more children are seeking such treatment because gender-inquiring children are more aware of their medical options and are less stigmatized.

Critics, including some in the transgender treatment community, say some clinics are too quick to offer irreversible treatment to children who would otherwise outgrow their gender questioning.

Psychologist Erica Anderson resigned as a board member of the World Professional Association for Transgender Health last year after raising concerns about the “sloppy” treatment given to children without adequate guidance.

She is still a member of the group and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor'” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates of the number of transgender youth and adults around the world vary, in part due to differing definitions. The association’s new guidelines say data from mostly Western countries suggests a range of between a fraction of a percent in adults and up to 8% in children.

Anderson said she has heard recent estimates suggesting the rate in children is as high as 1 in 5 – which she strongly disputes. That number likely reflects children who question sex and aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their children to receive transgender treatment and those who say treatment should be banned for those under 18.

“It’s absolutely cruel,” she said.

Dr. Marci Bowers, president-elect of the transgender health group, also raised concerns about hasty treatment, but acknowledged the frustration of people who have been “forced through arbitrary hurdles and hurdles to treatment by guardians … and subjected to a scrutiny that does not apply to another medical diagnosis.”

Gabe Poulos, 22, had her breasts removed at 16 and has been taking sex hormones for seven years. The Asheville, NC resident battled miserably with sexual discomfort prior to his treatment.

Poulos said he was happy to have been able to get treatment at a young age.

“To transition under the roof with your parents so they can go through this with you is really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a bill would ban transgender treatment for children under 18, Eli Bundy has been waiting for breast surgery since he was 15. Now 18, Bundy just graduated from high school and plans to have surgery before college.

Bundy, who identifies as non-binary, supports loosening the boundaries of transgender medical care for children.

“These decisions are best made by patients and patient families and healthcare professionals,” they said. “It certainly makes sense that there are fewer restrictions, because then kids and doctors can figure it out together.”

Dr. Julia Mason, an Oregon pediatrician who has been concerned about the growing number of young people receiving transgender treatment, said too many people in the field are taking the plunge. She argues that there is no strong evidence in favor of transgender medical treatment for children.

“In medicine…the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated children with outcomes in untreated children — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting drugs called puberty blockers in the early stages of puberty, which for girls is between ages 8 and 13 and usually two years later for boys. This is not a change from the group’s previous advice. Medication delays puberty and gives children time to decide on further treatment; their effects cease when the drug is stopped.

Blockers can weaken bones, and starting them too young in children assigned boys at birth could impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones—estrogen or testosterone—from age 14. This is often a lifelong treatment. Long-term risks can include infertility and weight gain, as well as stroke in trans women and high blood pressure in trans men, according to the guidelines.

— Breast removal for trans boys at age 15. Previous advice suggested it could be done at least a year after hormones, around age 17, although a specific minimum was not listed.

—Most genital surgeries starting at age 17, including removal of the uterus and testicles, a year earlier than previous recommendations.

The Endocrine Society, another group that offers advice on transgender treatment, generally recommends starting a year or two later, although it recently decided to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association allow children to seek transgender medical treatment, but they do not offer age-specific guidance.

Dr. Joel Frader, a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should be based on psychological readiness, not age.

Frader said brain science shows that children are able to make logical decisions around age 14, but are prone to risk-taking and don’t consider long-term consequences of their actions than when they are much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any area is not a one-size-fits-all option,” Williams said.

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Follow AP Medical Editor Lindsey Tanner on @LindseyTanner.

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The Associated Press Health and Science Department is supported by the Howard Hughes Medical Institute Department of Science Education. The AP is solely responsible for all content.

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