Literature Review Rough Draft
Puberty Suppression: A Review of Literature
Archie Kipp
University of Iowa
Introduction
Chances are that you’ve never wanted to physically transition to another sex as, “A survey of 10,000 people undertaken in 2012 by the Equality and Human Rights Commission found that 1% of the population surveyed was gender variant, to some extent.” (2016, para 38). Described as, “a conflict between a person's physical or assigned gender and the gender with which he/she/they identify” (Parekh, 2016, Para. 1), Gender Dysphoria(GD) seems to be at the epicenter of debate and controversy despite only applying to a small amount of the population. Some see men wearing dresses and perceive them as lost individuals who crave attention and ought to be seen as a threat to morality and a standard of culture. Others fight for the rights of Gender Dysphoric people’s and seek to make treatment for them more accessible. Whichever side of the fence you are on, or if don’t have an opinion either way, it should be agreed upon that these are human beings who are at great risk. Individuals suffering from GD have shown to be more susceptible to suicide and depression (Connolly, 2016, para. 14). These increased rates call for a need to treat this condition which can be found in the form of puberty suppression and eventual gender re-assignment. With gender-dysphoria becoming more of a common-diagnosis as the LGBTQ movement gains momentum, the use of puberty suppression on adolescents and children will likely become more and more prevalent. As this treatment gains traction, it’s important to understand the treatment, as well as the positive and negative effects.
Treatment
The treatment of puberty suppression involves the use of hormone injections based on psychological evaluations of patients. An gonadotropin-releasing hormone agonist(GnRHa) is a substance that stops the process of puberty by withholding the reproductive organs from other hormones that are required to make sex hormones (“NCI Dictionary of Cancer Terms”, n.d.). Initially used to suppress puberty in children with precocious puberty, GnRHa treatment has slowly become the primary choice for treatment of kids with Gender Dysphoria (Abel, 2014, p. 2). Paul Hruz, Lawrence Mayer, and Paul Hugh (2017), in a co-authored article, recognize how, “It was only in the 1990’s that GnRH analogues came to be used for the first time to suppress puberty in children who identify as the opposite sex.”(p. 14). Supporters of puberty suppression believe that kids who have severe gender dysphoria that take GnRH will have more time to explore their gender identity issues and stop the development of possibly irreversible sex characteristics (Weber-Main, 2011, p. 19).
Since the treatment has only been a recent occurrence combined with the minimal amount of participants, there is a lack of data concerning the long-term effects. However, the data that has been collected may seem to indicates a positive outlook for people who undergo a process labeled, “The Dutch Protocol”. This protocol suggests that children who have been diagnosed by multiple psychiatrists and psychologists to have Gender Dysphoria should start taking puberty suppression hormones either very early on, or before puberty, at approximately age 12 (Hruz, Mayer., & McHugh, 2017). Donna D’Alessandro (2018) expands on this by pointing out that to diagnose a child as gender dysphoric, and become eligible for puberty suppression, they must meet 6 out of 8 of the following psychological impairments for at least 6 months:
1. A strong desire to be of the other gender or an insistence that one is the other gender
2. A strong preference for wearing clothes typical of the opposite gender
3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preference for the toys, games or activities stereotypically used or engaged in
by the other gender
5. A strong preference for playmates of the other gender
6. A strong rejection of toys, games and activities typical of one’s assigned gender
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the physical sex characteristics that match one’s experienced
gender (“Discussion”, para. 7)
At around age 16, youths may be offered cross-sex hormones if they wish to continue with treatment, and once they reach 18, they are eligible for genital reconstruction surgery (D’Alessandro, 2018). In a study conducted of 55 young adults who underwent puberty suppression, subjects started taking GnRH at a mean age of 13.7, cross-sex hormones were introduced at a mean age of 16.7, and they underwent gender re-assignment surgery at a mean age of 19.7 (de Vries, McGuire, Steensma, Wagenaar, Doreleijer, Cohen-Kettenis, 2014).
Benefits of Puberty Suppression
Many studies and sources display a positive effect of puberty suppression.The Dutch Protocol was based on a 1998 case study conducted by psychologists Peggy Cohen-Kettenis and Stephanie van Goozen. It was the first case of a Gender Dysphoric person to use GnRHa to suppress puberty (Hruz et al., 2017). Peggy T. Cohen-Kettenis reappears to co-author with Sebastiaan E. E. Schagen, Thomas D. Steensma, Annelou L. C. de Vries, and Henriette A. Delemarre-van de Waal (2011), a follow up case study on the same subject. After undergoing GnRHa treatment from the age of 13, the gender dysphoric female, “B”, started undergoing cross-sex hormonal treatment, and later had multiple genital reconstruction surgeries in his 20’s. B was an intelligent person with good emotional problem-solving skills but experienced lots of insecurities and was hesitant, as well as very picky, to new friendships due to embarrassment concerning his transsexualism. At the age of 21, he reported no more signs of Gender Dysphoria. He was never acknowledged by anyone as a female; he acted like a male, and after surgery and the absence of developed female characteristics, he looked like one too (Cohen-Kettenis et al., 2011). It is also important to note that B has never regretted his decision. Similarly to the first study but on a larger scale, authors de Vries, McGuire, Steensma, Wagenaar, Doreleijers, and Cohen-Kettenis (2014), conducted a study of 55 children and adolescents who underwent puberty suppression. They continued to undergo cross-sex hormonal treatment and gender re-assignment surgery. They were assessed at 3 separate times to record data on patients’ well being and psychological functioning. Just as in the first study, after surgery adolescents were generally satisfied with how they looked, and none regretted the treatment.
Patients also displayed a quality of life, and subjective happiness and satisfaction with life that were consistent with the general population. Rates of depression, anger, and anxiety also dropped to normal levels. This data is extremely promising considering that a review of data on transgender youths found that, “Studies from a variety of settings have demonstrated that transgender youth have increased rates of depression, suicidality and self-harm, and eating disorders” (Connolly, Zervos, Barone II, Johnson, & Joseph, 2016, para. 16). Initial studies suggest that Puberty Suppression followed by hormonal treatment and eventually gender re-assignment surgery could truly benefit those suffering from Gender Dysphoria.
Negative Impacts of Puberty Suppression
Through the case studies seen thus far, it appears that The Dutch Protocol and puberty suppression as a treatment are effective for Gender Dysphoria. However, Paul W. Hruz, Lawrence S. Mayer and Paul R. McHugh (2019) write an article published byThe New Atlantis describing how they view the treatment as usually unnecessary and something that could possibly be harmful. They cite the DSM to show that,“most children who identify as the opposite sex will not permit in these feeling and will eventually come to identify as their biological sex” (p. 17). In a scenario such as this, Hruz, Mayer, and McHugh argue that this could lead children (most of them) who had gender dysphoria that would have been resolved in adolescence to have extended or permanent gender dysphoria. One could point to the previously mentioned studies to point out that no patient has experienced extended gender dysphoria (Cohen-Kettenis et al., 2014)(de Vries et al., 2014). In the article they describe how it is strange that none of the patients had regrets Factors such as puberty suppression, gender-affirmative psychotherapy, and other courses of treatment may have reenforced the idea of cross-sex identification, and that the treatment may have been ultimately unnecessary (Hruz et al., 2017).
In the study conducted on patient B, at the age of 35, the authors re-visit him to conduct another follow-up (Hruz et al., 2017). 15 years after his last interview, Hruz displayed lots of concerns regarding his metoidioplasty procedure. The authors described B as containing, “dissatisfaction and shame”, concerning his genital appearance and how his genitals worked. He could not partake in sexual intercourse and he could not pee standing up. Due to these limitations B found it hard to maintain a long-term relationship with his girlfriend. It is also important to note that none of the trans-men in the study of the 55 young adults had undergone a phalloplasty (de Vries et al., 2014). This displays a possible area of concern in the future as persons who engage in puberty suppression, and then gender reconstruction surgery, may experience more of an ostracism due to their lack of genital performance.
Conclusion
Puberty suppression is a recent form of treatment for Gender Dysphoric people developed in the last 25 that relies on a gonadotropin-releasing hormone agonist, or GnRH, to stop the production of sexual hormones. This is the first step in a process that leads to complete gender re-assignment. As a form of treatment, it has shown tremendous potential in studies concerning the alleviation of Gender Dysphoria and an overall emotional well-being. It also has been shown to reduce the elevated levels of depression and mental comorbidities that plague Transgender youth and adolescents. However, other evidence suggests that it may not be a truly necessary treatment and should be one that we use for only extreme cases. Future concerns may arise with patients using puberty suppression as they may experience a lack of utility following their genital reconstruction.
Puberty Suppression is a new field of study, having only been practiced for 25 years. Currently the oldest living subject is now around the age of 46 (Cohen-Kettenis et al., 2011). With no knowledge of the long-term effects of puberty suppression and only one example to examine, the error for margin in administering the treatment is very large. Many articles make the claim that the process of puberty suppression is reversible and subjects would continue on their developmental path(de Vries et al., 2014)(Abel, 2014)(Mahfounda, Moore, Siafarikas, Zepf, & Lin, 2017). However, Hruz, Mayer, and McHugh(2017) point out that there is no evidence or scientific data to substantiate this claim. More research must be conducted on how puberty suppression would continue if the subject decides they want to continue as their natal sex. Ultimately, puberty suppression appears to be a very exciting development with lots of positive data, but too little data and too many unknowns make it too experimental to be a reliable treatment for those with Gender Dysphoria.
References
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