Hormone treatment of gender identity disorder in a cohort of children and adolescents

To the Editor: I welcome the article by Hewitt and colleagues,1 but their protocol is problematic. Suppression of puberty improves mental health and general functioning, but not body image and dysphoria.2 For this, cross-sex hormones and/or surgery are the only effective treatments.2

Withholding cross-sex hormones until children are 16 years of age may worsen their mental health,3 cause resentment, and encourage self-medication. Increasingly, young transsexual people are using internet pharmacies to obtain hormones without prescription.

Transsexual children may undergo social transition and start high school with teachers and peers being unaware of their natal sex. Delaying cross-sex hormones (and hence, puberty) until the age of 16 years may lead to unwanted or ill-timed disclosure of their status and social ostracism. Additionally, remaining prepubertal while peers mature will reinforce feelings of difference in a group already at high risk of suicide.

The guidelines cited by Hewitt et al provide no epidemiological evidence to justify withholding hormones, and acknowledge that earlier treatment may be necessary to achieve appropriate height. The World Professional Association for Transgender Health standards of care do not impose an age restriction.4 Others argue that it is often infeasible to delay hormone therapy, and suggest earlier treatment.3 Experience at Boston Children’s Hospital supports earlier intervention.5 There is a risk that patients may end up regretting being treated, but this must be balanced by carefully evaluating the potential harm from delaying intervention.6 Some surgical procedures (eg, facial feminisation, mastectomy) may be necessary before the age of 18 years, as acknowledged in the standards of care.4 Delaying surgery may lead to self-inflicted injury (eg, breast binding), increase dysphoria and compromise personal safety.

Hewitt and colleagues’ assertion that surgery is “offered after transition to adult care providers” requires clarification, as adult services are almost non-existent. When they are available, few procedures are performed, and these are typically associated with substantial out-of-pocket expenses. Comprehensive adult services are therefore also urgently needed.