The Feasibility of Endocrine Interventions
in Juvenile Transsexuals
Louis Gooren, PhD, Henriette Delamarre-van
de Waal, PhD
Hospital of the Vrieje Universiteit in Amsterdam
[Abstract] Full Text [PDF]
Introduction
A large number of adult transsexuals recall
that their gender dysphoria started early in life, well before puberty. They
remember puberty with abhorence, since the hormones of puberty precisely
induced the body characteristics they prerceived as improper in relation to
their gender identity. The latter often reinforced their determination to
rid themselves from the primary and secondary sex characteristics. For most
of them, the time and period they grew up in provided not much room for the
expression of their gender dysphoria; they themselves often would not even
know how to label themselves until they learned about the phenomenon of
transsexuality. They all agree that his period in their lives has been a
vexation.
An incongruence between gender
identity/role can indeed be observed at an early age, as young as four years
of age. Zucker, Kuksis, and Bradley (1988) have reported that there are
young children who, from the moment they can talk, show their
dissatisfaction with the sex they are being raised in and behave as a child
of the opposite sex. These children are aware of their genital sex and often
hope that a "magical" solution for their problem will happen one
day.
With an expanding public information about
transsexualism, parents and caretakers seek professional advice for these
gender atypical children. Not all children with gender atypicality will turn
out to be transsexuals later in life. Several prospective studies of gender
atypical boys show that this childhood behavior correlates considerably
stronger with future homosexuality than with transsexualism (Green 1987;
Money and Russo 1979; Zuger 1984).
Now that juvenile persons with gender
problems come more frequently to the attention of the psychomedical care
system, some of the youngsters will turn out to be genuinely transsexual in
their mid-teen years; that is, there is no reasonable expectation that their
crosssexed gender identity will evermore change (Cohen-Kettenis 1994,
1995). The interests of such adolescents could be served with an early
start of (cross-sex) hormone treatment to spare them the torments of
developing the secondary sexual characteristics of a sex they view as not
their own. It goes without saying that eligibility for hormone treatment of
transgendered juvenile persons can only be the outcome of long-term
observation by experts in the field. It obviously requires parental
involvement in the decision until the age that they can legally make their
own decision on medical interventions.
The aim of this contribution is to describe
methods of hormonal treatment that might be of use in the above situation.
The psychological indications for this treatment, as well as the legal
implications of cross-sex (hormone) treatment of minors, is left aside.
It is understood that the approach should
be careful and cautious. It is to be remembered that giving, but also
withholding endocrine treatment is a momentous and responsible decision from
the side of the therapist with important implications for the person in
question.
In the first instance, it may be preferable
to halt the own hormonal pubertal development rather than induce hormonally
a cross-sex development. There are endocrine tools available to achieve
this; for the purpose we describe them, they have been mainly developed in
the care of children with precocious puberty. another approach is to
suppress some expressions of pubertal development of the child in question,
such as menstrual periods in young female-to-male transsexuals, leaving the
female development as such for the time being intact.
Endocrine Methods to Halt Pubertal
Development
There are several hormonal methods available,
but luteinizing hormone-releasing hormone (LHRH) agonists are the drugs of
choice.
Both the testis and the ovary are for their
sex hormone production dependent upon stimulation with the pituitary
hormones, luteinizing hormone (LH) and follicle stimulation hormone (FSH);
the latter hormones are in turn dependent on stimulation by a hypothalmic
hormone (LHRH). The latter hormone can synthetically be manufactured and
several chemical modifications have become available.
Some of these modifications exert
biologically an effect opposite to that of native LHRH: they bind so
strongly to the pituitary that endogenous LHRH can no longer exert its
effects, and therewith, the pituitary secretions of LH and FSH discontinues
and subsequently the gonadal production of sex steroids. Such LHRH agonists
induce therewith, so to say, again a prepubertal state of the subject, so
that the own puberty does not progress or even regresses. Or if given early
enough, before the first sign of puberty, the own puberty will not come
forth.
Several forms of LHRH agonists are
available; they differ in their biopotency, their duration of action, and
their route of administration. Their use is now widespread in the treatment
of a number of conditions of adulthood, such as prostatic cancer in men, and
of uterine myomas, polycystic ovarian syndrome, endometriosis, or fine-tuned
ovulation induction in women. A number must be administered on a daily
basis, either by subcutaneous injection or as a nasal administration. For
the purpose mentioned above, the long-acting, depot-intramuscular
preparations of LHRH analogues, such as depot leuprolide (Lucrin depot®,
Abbot) or depot triptorelin (Decapeptyl®, Ferring), are probably the most
suitable. The usual frequency of administration is every four weeks. The
effects must be sustained and, therefore, excellent compliance is critical
for success. But young transsexuals are usually keenly motivated to
cooperate. LHRH agonists are efficacious. Their effects are present already
after two weeks and after 4-12 weeks, sex steroid production is essentially
stopped. During the first year of treatment, growth velocity and the rate of
skeletal maturation decreases greatly if the subject was already going
through puberty. The initial expectation was that, as a consequence of
halting puberty with its eventual closure of the epiphyses, the final adult
height will increase. This has not come true in clinical studies. The latter
might been have an advantage for juvenile female-to-male transsexuals who,
when undergoing sex reassignment in adulthood, tend to be small men. The
average woman in the Netherlands is 12 cm smaller than the average man.
The effects of LHRH analogues are fully
reversible; in other words, no lasting undesired effects are to be expected.
Upon discontinuation of the LHRH analogues, the hormonal activity of the own
puberty is resumed within three months. Side effects are few, particularly
when there is usage only for a limited period of 3-18 months, as will be the
case with adolescent gender dysphoric persons. In their case, the issue is
often that they themselves are highly motivated to start with cross-sex
hormones, but the psychotherapist sometimes needs more time to work with
this person, or parental approval is pending or the personal educational
situation of the youngster makes it undesirable to start on cross-sex
hormones now or legal regulations prevent a start on cross-sex hormones at
this age. Treatment with LHRH agonists buys time for all parties in the
decision whether or not to start cross-sex hormones while the person in
question does not have the feeling that while this decision is weighed, the
irrevocable and irremediable of the undesired own pubertal development
speeds on. It follows that this process of decision making is limited in
time, and therefore, side effects such as insufficient formation of bone
mass (which occurs in cases of long-term sex steroid deficiency) are of no
great concern in this type of patient.
As stated above, LHRH analogues are the
drugs of choice for adolescents in this predicament, but if the are not
available, two other compounds, both also used with some merits in the
treatment of precocious puberty, can be considered: medroxyprogesterone
acetate in both boys and girls and cyproterone acetate in boys.
Medroxyprogesterone acetate is a progestational agent that can suppress LH
and FSH, the pituitary hormones that stimulate the ovary and the testis. It
is effective in halting the advancement of secondary sex characteristics in
both sexes and in preventing menstrual periods in girls. This drug is
available as an oral and an injectable preparation.
Medroxyprogesterone has weak androgenic
effects on bone maturation and is a weak glucocortoid. Side effects of
long-term use of this compound are related to these pharmacological
properties: adrenal suppression and cushingoid features with high doses and
salt and water retention.
In juvenile male-to-female transsexuals,
treatment with cyproterone acetate (Androcur®, Schering Pharma) may be
considered. It is a progestational compound with strong antiandrogenic
properties; it suppresses LH and FSH and counteracts the effects of
testosterone on peripheral organs. It is not available in the USA. Its
antiandrogenic properties give it an advantage over medroxyprogesterone.
Side effects are similar. A degree of gynecomastia may develop with this
treatment.
Other drugs that might be considered are
ketoconazole; it is an antifungal agent that inhibits testosterone synthesis
at the 17-20 lyase step, blocking the formation of androstenedione.
Testolactone is an inhibitor of the enzyme aromatase that converts androgens
to estrogens. Serum estradiol levels fall upon administration of this drug
and skeletal maturation is slowed, which may be an advantage in juvenile
female-to-male transsexuals. Spironolactone is an aldosterone antagonist but
it also has potent antiandrogenic properties by inhibiting the binding of
androgens to their receptors in the target organs. The clinical experience
with the latter drugs is not so extensive as with medroxyprogesterone and of
late LHRH agonists.
Suppression of some aspects of the
pubertal development
Teenage transsexuals may be helped if some
expression of belonging to the loathed sex can be suppressed. For young
female-to-male transsexuals, menstrual periods can be upsetting. This can be
achieved by low dose progestins. They are also used as progestin only
minipills in female contraception, but must in the case of transsexuals be
given without interruptions. The dose is so fine-tuned low that the tablet
must be taken each day at the same time. Examples are lynestrenol 0,5 mg
(Exluton®) and levonorgestrol 0.030 mg.
Older preparations with a higher progestin
content are lynestrol 5mg (Orgametril®, Organon) and norethisterone 5mg
(Primolut N®, Shering Pharma). For young male-to-female transsexuals,
erections and nocturnal emissions may be a painful reminder of unwanted
boyhood. These can be suppressed with cyproterone acetate (Androcur®,
Schering Pharma) in a dose of 1/2 to 1 tablet of 50 mg.
Gynecomastia may be a side effect and this
may not be wholly irreversible. Recently its safety has been questioned on
the basis of animal experimentation, but in its long-term clinical use it
has been found to be safe.
Conclusion
Teenagers with gender problems come to the
attention of the psychomedical profession. Reversible hormonal treatment of
juvenile transsexuals is breaking new ground, but the accounts of their
impossible and distressing situation are realistic. Professionals dealing
with this category cannot ignore their plight. Modern endocrinology can help
to create a frame where in the juvenile transsexual and the therapist can
work on the problem under less pressure of time rendering the gender problem
more amenable to the right type of treatment.
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Citation: Journal of
Psychology & Human Sexuality, Vol. 8(4) 1996 an article published on the
Internet <http://www.antijen.org/goren.html>
