New clinical guidelines, released Wednesday, are expected to reshape medical care for transgender children. The recommendations, written by an international medical team, ease previous restrictions so that children under 16 years old can begin hormone therapy in order to physically transform their bodies. The guidelines, which are being updated for the first time since 2009, are expected to carry wide influence among pediatricians across the globe.
The Endocrine Society, which boasts the “largest global membership” in the field of endocrinology, released the guidelines. Co-sponsors include the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Paediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society and the World Professional Association for Transgender Health.
Among the key changes: the doctors are reversing their position on “social transitions.” For the first time, the Endocrine Society acknowledges that young children may benefit psychologically from changing their hair and clothing to match the gender they believe to be as opposed to the sex they were assigned at birth. Another major shift: the authors of the clinical guidelines say that hormone treatment to change sex may be beneficial for kids younger than age 16. Previously, those drugs had generally been reserved for transgender people 16 and over. The shift is a controversial one that has some doctors and psychologists concerned that the new guidelines will encourage unnecessary transitions.
The new guidelines, however, are based on more than three years of work by an international team of endocrinologists and psychologists from major universities and hospitals in the U.S. and Europe, including the Mayo Clinic and University of California San Francisco. The guidelines will be published in the November issue of the Journal of Clinical Endocrinology & Metabolism.
“Together, we have worked … to optimize care, both on the mental health side and medical care,” said Dr. Steve Rosenthal, a member of the panel and an Endocrinologist who heads the Child and Adolescent Gender Center at UCSF Children’s Hospital.
Offering medical intervention at younger ages allows transgender children to physically transform more seamlessly and limit the number of costly and complicated surgeries later in life, according to Rosenthal.
“It makes it a lot easier for that person to blend in,” Rosenthal said. “If you go through female puberty and you have breasts, if you go through male puberty and you have an Adam's apple and a facial male structure, a deepened voice, all of these things are very difficult to change.”
The new guidelines recommend that only trained mental health professionals should diagnose and prescribe treatment for transgender patients. For adolescents seeking hormone treatment, they recommend gradually increasing doses, but only after a team of experts confirms that the adolescent is, in fact, transgender and has “sufficient mental capacity to give informed consent.”
Some in the medical community have expressed concerns over allowing young children to transition socially.
“I think it’s putting a lot on the shoulders of these children,” said Dr. Eric Vilain, a pediatrician and geneticist. “It’s putting them on a path that will have a lot of medical and surgical consequences.”
Vilain spoke to the Investigative Unit in April, prior to the release of the new medical guidelines. At the time, he was head of the Medical Genetics division at UCLA, but has since been named director of the Center for Genetic Medicine Research at Children’s National Health System in Washington D.C.
Vilain believes early social transitions unfairly push children to thinking they should identify as the opposite sex. He said these transitions can lead to unnecessary medical interventions for transgender kids.
"If the children are pushed in this belief it will be much, much harder for them to get out of this belief because everyone will have agreed on it very, very early on," Vilain said. "What worries me is that, indeed, there might be in the upcoming years a considerable number of these children that are placed on a path that we don’t fully know the outcome."
Vilain points to numerous studies that conclude that 80% of people who think they are transgender eventually change their minds.
However, Rosenthal and the doctors behind the new guidelines point out that many of those studies are outdated - some from the 1970s and 1980s. They believe that in those past studies many people were misdiagnosed as being transgender. Those people, they say, are the ones who eventually reverted back to their biological sex.
One of the transgender adolescents who may be affected by the new treatment guidelines is 12-year old Jack, a transgender boy who began socially transitioning last year. The Bay Area 7th grader was born Sophia, but now identifies as Jack.
“Sure, I’m a kid, but it doesn’t take a genius to realize that I’m not a girl,” he said.
“Sophia was there in my head, but Jack was also,” he said. “I see her as a different human being than I am. I’m Jack - and Sophia had her own lifetime - and I have my own.”
Jack recently underwent a medical procedure to have a tiny device implanted in his left arm that pumps medications through the body to stop the effects of puberty. For now, Jack’s puberty is on hold. Under the new guidelines, he no longer has to wait until he turns 16 to being taking male hormones.
An estimated 1.4 million adults and 150,000 teens in the U.S. identify as transgender. Population figures for younger children, however, are largely unknown. That said, Bay Area gender clinics provide care to more than 550 children, according to data collected by the NBC Bay Area Investigative Unit.
CORRECTION: An earlier version of this story implied that Dr. Eric Vilain strongly disagreed with the new Endocrine Society guidelines. Dr. Vilain contacted the Investigative Unit to say that his comments about social transitions should not be construed as opposition to the guidelines. This story has been updated to better reflect Vilain’s position and to clarify that his comments were from an interview in April, prior to the September release of the new guidelines.