“Puberty was f***ing horrendous,” exclaims Ashton Power, an 18-year-old transgender man who wears black-rimmed glasses and streaks of purple in his light hair. Born in Germany, Power lived in Eritrea, in East Africa, before moving to China, Singapore, and finally Hong Kong where his family has been for the past seven years.
Shortly after arriving in Hong Kong, Power realised he was transgender. He was 11 at the time, and the realities of puberty were just starting to set in. “I wish those years hadn’t happened. I started becoming more aware of my physical body … that we are not all just the same gender, there are differences,” he says, glancing down. “It doesn’t help that I have other mental issues – generalised anxiety disorder, major depressive disorder, ADHD, and autism spectrum disorder – but it was horrible.”
Power first came out to a few friends online, then his parents, only later telling friends and teachers at school. As part of the process to shed his assigned identity, he adopted a new name and pronoun. Power says these important changes decreased gender dysphoria, a condition in which a person feels distress due to incongruence between their internal gender identity and their sex assigned at birth.
“I was feeling so much tension every time I heard my [old] name. In terms of my physical appearance, I have always tried to just ignore my entire existence – that is my whole coping mechanism … I have had many breakdowns over it. At one point, I ended up getting admitted to Queen Mary Hospital for self-harm.”
Feeling deeply distressed as his body changed, Power knew that the more he developed, the harder it would be to undergo gender transition surgery later. “I first brought up being trans to my parents because I had read about hormone blockers [drugs used to delay the physical aspects of puberty].
I remember saying something like, ‘Hey, could we maybe go ask the GP [general practitioner] about the possibility?’”
According to Power, his parents thought it was just a phase and did not believe puberty blockers were the right step. “My parents didn’t want to encourage me [to be transgender]. But my feeling was, well, if it is just a phase, then I can stop taking the hormone blockers. That’s the point of them – buying time – so we can figure it out.”
“In terms of my physical appearance, I have always tried to just ignore my entire existence – that is my whole coping mechanism.”Ash Powers
Buying More Time
Hormone blockers, also known as puberty blockers, are not a new phenomenon. In fact, the most common type of puberty blocker, gonadotropin-releasing hormone analog (GnRHa), has been widely used for more than 30 years to treat precocious puberty (when puberty occurs at an unusually early age).
In a 2015 study on the long-term impact on Korean female patients, published in the Korean Journal of Pediatrics, researchers found the drug to be safe and effective. When the youth stopped taking GnRHa puberty restarted within one year and, in the long term, no abnormalities in reproductive function developed. During the GnRHa treatment, researchers found that bone mineral density decreased, but rebounded to normal density over time.
In the late 1980s, the Amsterdam Gender Identity Clinic at the VU University Medical Center in the Netherlands became one of the first clinics to administer puberty blockers when treating individuals with gender dysphoria.
Most commonly, endocrinologists administer injections of GnRHa which will block hormones for a few months at a time. Once administered, GnRHa restricts the pituitary gland’s secretion of estrogen or testosterone to halt the physical changes that would normally occur during puberty. In terms of its reversibility, puberty will restart roughly six months to one year after the child stops taking puberty blockers.
“It’s often more important to block puberty in biological males because it’s much harder to make cosmetic alterations once men start getting tall, broad, and hairy. And once their voice goes down, there’s no way to get it back up,” says Dr James Cantor, a Canadian clinical psychologist and sexologist who studies atypical sexualities and the gender spectrum.
Over time, the VU clinic developed a protocol that has come to be known as the Dutch model, which has been adopted by physicians and psychologists around the world. Essentially, a multidisciplinary team of physicians, psychologists, endocrinologists, and social workers practice a ‘watchful waiting’ approach to see if a child expresses persistent, consistent gender dysphoria.
Doctors also use this approach to rule out other potential issues, such as a sexual orientation or borderline personality identity (characterised by rapid changes in identity, unstable relationships, significant distress, mood swings, chronic feelings of emptiness, fear of abandonment and anxiety).
“If somebody is suicidal because they have borderline personality disorder, they will still suffer even if we ease [gender dysphoria] and cure all the transphobia in society, which I hope we will one day,” says Dr Cantor. “By failing to recognise other mental health issues that could be going on, we’re not doing anybody any good … We need to make sure that the person gets all the right resources.”
If gender dysphoria persists in the earliest stages of puberty, the Dutch model recommends a ‘real-life experience’ phase in which the individual lives in their adopted gender, which entails adopting a new name, pronoun, and dressing how they feel most comfortable.
If the child still experiences gender dysphoria and a desire to live in the opposite sex by age 12, doctors may then administer reversible puberty suppression for up to four years, with frequent monitoring and counselling.
And if a desire to transition remains at 16, the Dutch model calls for partially reversible hormone treatments until the individual is 18 years old. At that point, they may continue with hormone therapy or pursue gender reassignment surgery.
Doctors say that experiencing a little bit of puberty is important: Studies show that between 73 and 94 per cent of children who experience gender dysphoria will no longer want to undergo a gender transition by puberty.
“All of a sudden, sex drive kicks in, and many [gender-diverse] kids realise who they are attracted to. The majority figure out that they’re gay or lesbian,” says Dr Cantor. “It depends on the study, but about a quarter or a third will continue to feel that they want to live as the other sex. Now the ones who still want to live as the other sex by the time puberty comes? That’s pretty permanent.”
Indeed, studies show that youth who experience sustained or exacerbated gender dysphoria during puberty are more likely to continue identifying as transgender through adulthood. In Hong Kong, about 10,000 to 20,000 people are transgender, according to conservative estimates by the Transgender Resource Center.
Dr Michael Eason, a Hong Kong psychologist who specialises in working with LGBT+ clients in private practice at Lifespan Counseling Central, says that puberty blockers are a way of “buying time” and “pressing pause” so that doctors can work with the child and family.
“There’s a lot of distress around the physical body, especially when puberty hits. A lot of transgender individuals feel like their body is betraying who they are,” says Eason. “If you can imagine, looking in a mirror, there is a constant sense that there’s a mismatch between who you are and what you see. It’s as if your reality, your core identity, is sort of split or torn. It’s a constant tension.”
In addition, he says transphobia in society can cause or aggravate gender dysphoria. “A lot of the stress and discomfort comes from discrimination, bullying, teasing, and things of that nature,” says Eason. “You know, being a teenager is hard enough. But as a trans teen, you are navigating a very confusing world with an added layer of social stigma.”
Some children will wear baggy clothing to cover up their bodies, others may bind their breasts which can seriously damage their ribs. Many feel a sense of “wanting to disappear” due to the serious, continuous feeling of distress, anxiety, and depression, he says. “The statistics are really staggering in terms of suicidal thoughts, self-injury and substance abuse amongst transgender individuals.”
In Hong Kong, over 70 per cent of transgender youth have contemplated suicide, according to “Mental Health of Transgender People in Hong Kong”, a 2016 survey by the Chinese University of Hong Kong. Another study, published by the American Academy of Pediatrics in 2020, examined associations between puberty blockers and mental health.
Surveying 20,619 transgender adults between 18 and 36, the study found that those who had access to puberty blockers in youth were less likely to experience suicidal thoughts, compared with those who were denied puberty blockers.
In Eason’s experience, many times it is the children themselves who research hormone blockers and ask about the possibility. Other times, parents bring it up in conversation to see if that’s an appropriate pathway. If so, Eason works with a team of professionals, including the family’s general practitioner and an endocrinologist, so they have access to different opinions and can make an informed choice.
“The big question is around emotional maturity: Do you trust your child? How mature are they with regards to other decisions they make?” says Eason. “If every other kind of aspect of this child’s life has been very organised and thoughtful, why would this decision be any different? And that’s what I’m talking about: giving the kids credit for their own self-awareness.”
Understanding The Risks
Several studies have found that puberty blockers are effective, reversible, and safe to administer to adolescents when taken for no more than four years. However, some unknowns still exist, since GnRH analogs have only recently started to be used specifically for this purpose.
In 2006, the European Journal of Endocrinology published a research article on the clinical management of gender identity disorder in adolescents. It found that the suppression of puberty is a “very helpful diagnostic aid” that not only enabled more time to clarify potential gender confusion but also enabled “improvement in the quality of life in these individuals.”
It both lowers the incidence of postoperative regrets or poor functioning, and minimises physical changes, allowing transgender individuals to more easily pass inconspicuously in their gender expression.
“This holds especially for MFs [male-to-female transitions] because beard growth and voice breaking give so many of them a never-disappearing masculine appearance,” the study reads.
“But, since the number of ‘false positives’ should be kept as small as possible, the diagnostic procedure should be carried out with great care. Until now, no patients [in the study] who started treatment before 18 years have regretted their choice for SR [sexual realignment].”
In 2014, The Journal of Pediatrics published a longer-term longitudinal evaluation of the effectiveness of GnRH analogs in the treatment of adolescents with gender dysphoria, assessing them before puberty suppression, as well as before and after gender reassignment surgery. The study evaluated 55 young transgender adults, all of whom reported an improvement in general functioning two years after the operation, along with a decrease in depression and emotional difficulties.
Still, a dearth of long-term studies worries some parents and doctors. Most cite concerns about stunted growth or bone density loss, which have yet to be studied long-term.
“We want to educate the parents and the child about the pros and cons. For instance, the trials and understanding of puberty blockers, especially their effects on bone density or cognitive development, are still in progress,” says Eason. “It’s a very difficult choice. But puberty blockers are reversible, so I think any of the potential cons just pale in comparison to a child’s everyday suffering. Some families will gladly accept the risk in order to alleviate their child’s extreme distress on a psychological level.”
As hormone blockers gradually become more available, many critics are voicing opposition around the world. Last March in the UK, Oxford professor Dr Michael Biggs accused the NHS Gender Identity Development Service (GIDS) of covering up the potential long-term negative impacts of administering GnRHa to adolescents in a 2011 study.
[Read more: The meaning behind LGBT+ terms]
In his critique of the NHS report, Dr Biggs said that the foundation had underplayed “statistically significant increases” in instances of self-harm, behavioural and emotional problems, and physical wellbeing. He also expressed concern about physical effects – such as bone density and height, which can be slowed or reduced until the child is taken off hormone blockers or switches to cross-hormone therapy – and the unknown long-term impact this has on metabolism, fertility or sterility.
In addition, a landmark High Court case against the Tavistock and Portman NHS foundation trust began in January 2020. The claimants, Mrs A, the mother of a 15-year-old autistic girl who is on the GIDS waitlist to receive treatment, and Susan Evans, a former Tavistock nurse, sued the foundation for giving children experimental treatments without adequate testing or regulation.
“The alarm bells began ringing for me when a colleague at the weekly team clinical meeting said that they had seen a young person four times and they were now recommending them for a referral to the endocrinology department to commence hormone therapy,” wrote Evans on CrowdJustice, a crowdfunding website for legal cases. When hearings conclude, the High Court will decide if the NHS can continue to legally administer puberty-blocking drugs to adolescents.
In the US, it’s a state-by-state issue. Republican senators across over a dozen states are pushing to ban puberty blockers on the grounds of protecting children. For example, a New Hampshire bill, if passed, would characterise gender dysphoria treatments including puberty blockers as ‘child abuse.’
Lawmakers in South Dakota, meanwhile, argue that prescribing puberty blockers should be a criminal offense, punishable with fines and prison time. In stark contrast, Oregon state funds hormone suppression treatment for children on the Oregon Health Plan (public health insurance for low-income individuals and families).
“There is a saying: ‘When one family member transitions, the whole family transitions.’”Dr Michael Eason
“This issue has been highly politicised and there are extremist views on both sides. There exist people who are just transphobic and homophobic, saying, ‘nobody should be able to transition, this is unnatural.’ There are also people who think every child should be able to transition on-demand without checking out everything first,” says Dr Cantor.
“We don’t have to wait until an individual is 18, but the evidence suggests that age 12 is the correct waiting point. You have to set those extremes aside and follow the science.”
In Hong Kong, adolescents can access hormone blockers through private clinics as long as they have been clinically diagnosed with gender dysphoria, have displayed a sustained desire to transition and have obtained parental consent. It is a case-by-case scenario, determined by the child’s distress, emotional maturity, cognitive development, and the presence of other psychopathologies.
The Hospital Authority (HA) does not currently administer hormone-blocking medications in relation to gender identity concerns. A spokesperson for GID at Prince of Wales Hospital tells Ariana that the clinic references the World Professional Association for Transgender Health (WPATH)’s Standards of Care (SOC), which outlines recommendations for puberty suppression, but the clinic eschews hormone blockers.
“The extent to which the SOC could be applied varies from place to place” says the spokesperson. “As stated in the [WPATH] SOC, health professionals must be sensitive to the cultural differences and adapt the SOC according to local realities.”
A Family Transition
While debates are inevitable, nearly every major medical association in the US, including the American Psychological Association and Endocrine Society, has deemed puberty blockers a safe, effective tool, which can buy more time and relieve distress.
According to the multidisciplinary Dutch model, which is widely accepted as one of the best practices at this time, doctors should carefully observe how gender dysphoria develops in the first stages of puberty. If gender dysphoria persists or worsens, doctors will consider puberty blockers on a case-by-case basis, alongside pediatric endocrinological advice and regular monitoring.
Power, who is preparing to start hormone replacement therapy at the Prince of Wales Hospital’s Gender Identity Disorder (GID) Clinic in Hong Kong, recommends that parents, teachers, and doctors give children space and time to better understand themselves.
“Puberty blockers aren’t going to be right for everyone. I think each person has to discuss it with their doctor and be open to the potential that they aren’t actually trans,” says Power. “There are cases of de-transitioning, so be aware that it could change and that it’s okay for that to happen.”
“In my case, my mum was really concerned that it was just a phase, that maybe I would change my mind but not feel comfortable doing so. But the thing is, if you put up a fight to allow a child to identify as trans in the first place, then it’s going to be harder to go back to the way it was before if it really is a phase.”
A 2016 study published by Pediatrics, the official journal of the American Academy of Pediatrics, showed that teenagers who felt supported in their transition seem to be no more depressed and only slightly more anxious than their cisgender peers. Eason recommends parents lend support by communicating openly and without judgment about their child’s gender identity.
“A large piece of the therapy is working with the families around education and acceptance, but there can be a process of grief and loss with the parent – [they may feel like] they are losing a son and gaining a daughter or losing a daughter and gaining a son. Each situation is unique; some parents may need to grieve the future they had for the child and accept their child’s new identity.”
This grief, he says, often goes unacknowledged. “People want parents to be cheerleaders and all that. They do need to be supportive, but we also need to acknowledge that this is a process for parents as well. There is a saying: ‘When one family member transitions, the whole family transitions.’ It is a process.”
By The Numbers
10,000-20,000: Adults identify as transgender in Hong Kong, by conservative estimates
2,100: The number of people who have sought gender-related care at Prince of Wales Hospital’s GID Clinic in 2019-2020
18 weeks: Median wait time for new patients AT THE GID CLINIC
70: Number of new psychiatric cases at GID in 2019-2020
– May help relieve anxiety, depression and/or suicidal thoughts
– Buys more time for medical professionals, families, and adolescents
– GnRHa analog-treated adolescents can pass more easily in the other gender
– Makes some transition-related surgeries unnecessary or less invasive
– More longitudinal research needed to understand full impact
– Could affect bone density, sexual function, height, and reproductive organs if taken longer than recommended
– Some children experience headaches, hot flashes, and higher BMI
– The child may not experience age-appropriate sexual desires