Altering the appearance of one’s gender through hormone treatment or surgery is a permanent decision with lifelong health consequences that go beyond cosmetics
Brittle bones, affected brain development, and the loss of a functioning reproductive system are among the possible side effects of gender transition.
It is crucial for those seeking treatment for gender dysphoria to consider the lifelong consequences of such treatments, but that is a tall order for young patients with still developing brains and bones and who have not yet hit puberty.
It is also a tough task for those on the autism spectrum, who are seen at a higher rate in the transgender community compared to the general population, according to doctors at the Gender and Sexuality Development Program at the Children’s Hospital of Philadelphia (CHOP), speaking in a Pennsylvania taxpayer-funded series of transgender therapy training workshops for workers in health care and education.
Reversible Treatment Leads to Irreversible Outcomes
The CHOP trainings teach mental health providers to treat children under age 8, first with reversible methods such as “acceptance and affirmation.” The training advises professionals to guide families through social gender transition by choosing a name, haircut, clothing style, and public bathroom of the gender the child wants to be.
Not considering mental health effects, these strategies can be reversed.
But puberty blocker medicines may start between ages 8–14. Ages 14 and up can be treated with testosterone, estrogen, and “gender affirming surgeries,” the training advises.
The decision to give a child puberty blockers can have permanent effects.
Puberty blockers can “put the pause button” on puberty, giving children more time to explore their gender identity, the training claims, and prevent children from the development of “irreversible secondary sex characteristics,” such as the natural development of breasts or deepening of the voice. If these characteristics never develop, the child may not need surgery later, the training indicates.
Higher Risk of Bone Fractures
Hormones are needed to build bone during puberty, so children taking puberty blockers will have weaker bones during development and throughout adulthood, putting them at higher risk of bone fractures, said Dr. Zachary McClain in one of the trainings. McClain is assistant professor of pediatrics at the Perelman School of Medicine and program director of adolescent medicine.
“What we know about puberty blockers is that they actually lower your bone mineral density during puberty,” McClain said. “But the good news is, when we start back with cross-sex hormones, with either estrogen or testosterone, that bone density goes right back up.
Does it go back up to someone who’s never been on puberty blockers? Probably not. There was one study that did show that it didn’t go back up to cisgender youth who just went through a normal cycle of puberty.”
Blockers may also stall cognitive brain development, McClain said.
“It’s not going to change how smart they are, but there is this abstract cognitive development that we’re just not sure about. … Some of the science is there, some of the science isn’t there, but we know in general, these are safe,” said McClain.
Puberty blockers are not approved by the Food and Drug Administration for use in gender transition, the training said.
Children on puberty blockers may be shorter than their peers. They will grow at the slower, pre-puberty rate, and grow faster once they are on cross-sex hormones, he said.
Those undergoing gender treatments have an increased risk of mental health challenges, including more anxiety disorders, mood disorders and a higher rate for suicide, and there are more instances of autism than in the general population.
Informed Consent
The World Professional Association for Transgender Health (WPATH) recommends in its eighth Standards of Care report that doctors ensure patients understand the effect of gender treatment on reproduction before beginning treatment.
“Gender-affirming medical interventions often affect reproductive capacity,” the report said. For example, removal of testicles is irreversible and leads to loss of fertility and loss of the effects of endogenous sex steroids.
Clinical data indicate that after gender care, transgender people score significantly lower in sexual pleasure compared to cisgender individuals, and they should be informed before treatment.
But transgender women can still get pregnant, even while taking testosterone.
“We recommend medical providers discuss contraception methods with transgender and gender diverse people who engage in sexual activity that can result in pregnancy,” the report said. Transgender individuals may retain reproductive capacity, and may experience unplanned pregnancies due to an erroneous assumption that testosterone is a reliable form of contraception.
“Transgender men and … people who use testosterone should be informed 1) although quantities are small, testosterone does pass through chest/breast milk; and 2) the impact on the developing neonate/child is unknown, and therefore gender-affirming testosterone use is not recommended during lactation.”
Testosterone therapy may cause high cholesterol and estrogen may cause blood clots. Other hormone therapies can cause weight gain, depression, increased frequency of urination, low blood pressure, and the onset of osteoporosis.
There will be more doctors visits. Women who surgically add male genitalia should expect lifelong urological follow-up appointments. Men who surgically add female genitalia will still need regular prostate exams plus gynecologic exams to check for complications.
The report says a small percentage, between 0.3 percent and 3.8 percent, will regret their decision to change the appearance of their gender.
Regret can be temporary or permanent and may be classified as social regret, often caused by difficulties in familial, religious, social, or professional life; medical regret, due to long-term medical complications, disappointment in surgical results or inadequate preoperative decision-making; and true gender-related regret, mostly based on patient-experienced misdiagnosis, insufficient exploration of gender identity, or both, the report said.
Alternative Decision Maker
Within transgender treatment circles there are discussions about the importance of informed consent, the ethical principle that recipients of health care should understand the health care they receive and any potential consequences that could result, according to the WPATH report.
“It is important to recognize mental illness, in particular symptoms of cognitive impairment or psychosis, can impact a person’s ability to grant consent for gender-affirming medical and/or surgical treatments (GAMSTs).
However, the presence of such symptoms does not necessarily equate to an inability to give consent because many people with significant mental health symptoms are able to understand the risks and benefits of treatment enough to make an informed decision,” the report said.
The report added that it is important that a careful assessment is done, examining a person’s ability to comprehend the nature of the treatment being considered, consider treatment options, including risks and benefits, appreciate the potential short- and long-term consequences of the decision, and communicate their choice in order to receive the treatment.
The report recommends mental health professionals address mental health symptoms that interfere with a person’s capacity to consent to gender-affirming treatment before treatment is initiated.
“There may be instances in which an individual lacks the capacity to consent to health care, such as during an acute episode of psychosis or in situations where an individual has long-term cognitive impairment.
However, limits to capacity to consent to treatment should not prevent individuals from receiving appropriate GAMSTs,” the WPATH report said. “For some, understanding the risks and benefits may require the use of repeated explanations in jargon-free language over time, or the use of diagrams to facilitate explanation and aid comprehension.”
In some cases, an alternative decision maker, such as a legal guardian or regulator-approved, independent decision maker may need to be appointed, the report said.
The goal is to provide “the most affirmative and least restrictive health care.”