May 21, 2008 -- A procedure that some are mistakenly calling a sex change treatment for children has been drawn into the spotlight in recent days -- although it has been going on for many years.
In an interview with National Public Radio broadcast earlier this month, Dr. Norman Spack, a pediatric endocrinologist at Children's Hospital in Boston, revealed that he has at least 10 pediatric transgendered patients to whom he has been giving a hormone-blocking treatment to delay puberty.
Citing recent unwanted media attention, Spack declined, through a spokesman, to be interviewed for this article.
But other doctors say that while Spack may be the first to go public about what he is doing, he is not the first to help children delay their puberty so they can reach maturity before deciding if they would like to transition to the opposite sex..
Milton Diamond, a sexual development researcher and the director of the Pacific Center for Sex and Society at the University of Hawaii, says he knows of doctors who have done this before, "but people don't generally advertise it," he says.
He pointed to the Netherlands, where hormone-blocking therapy has been administered to transgendered youths for more than 20 years.
But Diamond says that the hormone-blocking therapy itself is not sex reassignment.
"It's a delaying tactic to allow the individual to come to terms with the direction he or she wants to go," he says. "What you're doing is allowing the individual more time to make a decision."
Is It Safe?
Jamie Newton, a spokesman for Children's Hospital, confirmed that the treatments are done in accordance with the Harry Benjamin guidelines (generally accepted clinical guidelines for treating transsexual patients), which call for fully reversible treatments for prepubescent children.
The therapy entails an injection of either luteinizing hormone-releasing hormone (LHRH) or medroxyprogesterone, which block estrogen or testosterone to delay the onset of puberty.
The regimen is typically given to children (mostly girls) who reach puberty very early, when the parents and physician opt to delay the process a few years to aid with normal development.
Medroxyprogesterone is known commercially as Provera, a drug injected once every three months as a birth control medication.
"LHRH has been used for 20 years, medroxyprogesterone probably that long, if not longer, so we know they're safe and effective," says Alan Rogol, a clinical professor of pediatrics at Riley Hospital of the Indiana University School of Medicine and the University of Virginia.
Also, he says, a child will undergo normal puberty following the hormone-blocking treatment, and it is fully reversible should a transgendered child choose not to undergo sex reassignment or transition once they reach adulthood.
"There is no question that it's reversible, and I'm unequivocal about that," says Rogol.
In addition to delaying the onset of puberty, the hormone-blocking process does help patients avoid unwanted bodily features if they do decide to undergo a sex change upon reaching adulthood. It is the changes of puberty that often cause the most distress for transgendered children.
"We're talking about things that have a profound, significant influence on the child's life," says Diamond.
Male transsexuals can avoid going through menstruation, while female patients can avoid growing body hair or developing a deep voice if they begin sex reassignment once their childhood hormone-blocking regimen ends.
Transitions and Follow-Ups
Although the treatment is reversible, Diamond says that most who reach that point will go on to transition.
"Almost all those who have gender identity disorder continue on to surgery, or at least continue on to transitions," says Diamond.
In his interview with NPR, Spack confirmed that assessment.
"My confidence comes partly because I've yet to see one change their mind and partly because we're using the psychological testing methods the Dutch have perfected, and they've yet to see one person change their mind," he says.
While the procedure allows children to more easily undergo sex reassignment upon reaching adulthood, sex reassignment surgery is controversial.
First performed in the first half of the 20th century, sex reassignment surgery gained prominence when former soldier George Jorgenson underwent the operations in Europe and became a media sensation as Christine Jorgenson.
In 1966, the Johns Hopkins Hospital announced that it was performing sex reassignment surgery through its Gender Identity Clinic. Those procedures were halted in 1979, when a study by Dr. Jon Meyer, a follow-up on patients who had undergone the operations, did not show any improvement in their wellbeing.
Dr. Paul McHugh, then the head of the psychiatry department at Hopkins, made the decision to halt the procedures, saying they destroyed healthy organs and that physicians needed to focus on healing transgendered persons' minds, rather than altering their bodies.
Many transgendered persons continue to undergo sex reassignment surgery, although a great number of them do so abroad. Because of a lack of reporting, exact numbers are hard or impossible to come by.
Since Johns Hopkins closed its clinic, no other hospital of that stature has made a public announcement of resuming the surgeries.
How Do You Know?
The closing of the Hopkins clinic led some to question how to tell when someone is truly transgendered, particularly children, who may simply have interests more often associated with the opposite sex.
"That always involves clinical judgment," says Diamond. "How do you know, when you're talking to a friend if he's pulling your leg? The more you know about a person, the more you can judge if he's lying or not. You don't make those decisions on one interview."
The important thing, says Diamond, is to be careful and aware that errors can be made in treatment.
"You have to be a little bit humble and realize you may make a mistake," he says.
But, he says, when used properly, delaying puberty until they are adults may be the best way to help a number of transgendered children grow into successful adults.
"If I thought it was appropriate, I wouldn't have hesitation in doing it," says Diamond. "I think it's a worthwhile practice, but like everything else, it has to be used judiciously."