Irreversible damage or necessary intervention? What parents of trans kids need to consider about transitioning early

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"The journey of any two individuals, and any two children is going to be different."
"The journey of any two individuals, and any two children is going to be different."

Laws around our children's consent caused a furore when Covid vaccines were approved for teens and pre-teens aged 12 to 18. There was an outcry among some parents who refused to believe that their children had – as per The Children's Act – "sufficient maturity…to understand the benefits, risks, social and other implications of the treatment".

Similarly, most parents' blood would run cold at the thought that our children –aged 12 and up – have legal autonomy in South Africa to medically transition to another gender without parental consent (this is also assuming they have access to finances and safe, reliable healthcare).

However, there's no reason to fear that your teen or tween might be a boy one day and a girl the next. And certainly not before you or they have had time to consider the route forward and process this major life change.

A model of informed consent

In her own practice as a gender-affirming general practitioner, Dr Anastacia Tomson aims first to establish an honest and open relationship between herself, the parents and their child. Like all affirmative healthcare professionals should, she operates on a model of informed consent, arming both parent and child with all the information they need to take the best route forward (one that most benefits the child).

"There is no textbook description of what this is going to look like. The journey of any two individuals, and any two children is going to be different," says Tomson.

Together, all parties consider the child's feelings and beliefs about their identity, their physical and mental wellbeing, and how close they are to puberty (which impacts on the treatment timeline).

"There isn't a checklist. I give people options and educate them about those options so they can make their own decisions. It is up to the child and their family which path they take," says Tomson.

Informed consent will include discussions around fertility, the benefits and risks of medical intervention, the adverse effects of hormone treatment, an appropriate safety and monitoring process, and whether it's possible to wait a bit before treating medically. That said, it's crucial to find a gender-affirming healthcare provider who is experienced and competent in this field.

Skilled mental health care is crucial

In line with The World Professional Association of Transgender Health (WPATH) and Professional Association of Transgender Health of South Africa (PATHSA) guidelines, it's crucial for a suitably skilled mental health practitioner to be part of the evaluation and support of transgender youth.

Child and adolescent psychiatrist Dr Simon Pickstone-Taylor notes that transgender children and teens often have co-occurring conditions, like autism spectrum disorder, which are equally important to identify and support appropriately.

"It's been consistently shown in studies that the outcome is much better for transgender youth if parents are fully supportive of their needs. Giving parents all the information they need to understand their child in an evaluation, and what research shows would help their child best, is a complicated and very important process that needs to be managed by a clinician with the appropriate mental health and paediatric training and skills," says Pickstone-Taylor.

Putting the brakes on unwanted changes

According to WPATH and PATHSA guidelines, gender-diverse children will be put on hormone blockers once very early puberty starts (Tanner Stage 2). This intervention is designed to buy time by putting the brakes on further physiological development. 

"This is a reversible intervention. It means we stop the production of biological hormones and delay the administration of exogenous hormones, assuming that is the route forward," explains Tomson.

However, hormone blockers are not completely without consequence, as it means that a child will enter puberty later than their peers, impacting on social development. This, however, is all part of the model of informed consent.

"Clinicians need to work with the particular child and their circumstances to try and bring about the best outcome for them," says Pickstone-Taylor, adding that nothing is done without both parents and child being properly informed, or without the child wanting intervention.

"Parents are given the appropriate information to help understand why their child needs the intervention, and they consent on the child's behalf where necessary, as is done for children with cancer who require surgery," he adds.

On occasion, one parent might agree, while the other does not. But, ideally, both parents and their child will give consent together.

Sometimes, there's no need for intervention

Younger trans children, who have yet to hit Tanner's second stage of puberty, will not need medical or surgical intervention, says Pickstone-Taylor.

This is the stage of puberty before any noticeable physical development or growth occurs in the form of pubic hair, larger testes or breast buds. It normally occurs between the ages of 9 and 11 for girls, and at age 11 for boys.

The psychiatrist notes, however, that being allowed to socially transition in a supportive environment is a huge game-changer for gender-diverse children.

"Invariably, we see a dramatic improvement in children. As soon as supportive measures are put in place, somatic problems (physiological ailments) start to abate, school refusal stops, and emotional and behavioural problems disappear. Kids are allowed to grow and thrive in a healthy way once their parents and the world around them finally start gendering them correctly and stop forcing them to act like someone they are not," says the psychiatrist.

Child-led social transitioning

A 'social transition' involves any non-medical changes that will help bring a child in line with their gender identity. These types of changes might include:

  • Changing the child's name and pronoun
  • Changing the child's school uniform and other clothing options
  • Allowing the child to use toilets that align with their gender identity
  • Allowing the child to play sports that align with their gender identity

Pickstone-Taylor notes that a child should never be pushed or coerced to make any changes they are not ready for, or do not want. 

"The professional's role is to first get the child's parents to understand the importance of respecting their child's gender identity and allowing them to express it freely." 

By the same token, school staff will also need to be educated and supported through the transitioning process.

"There are now over 40 schools (both private and public) in the Western Cape where children have socially transitioned with professional support," says the psychiatrist. 

He adds that, in his experience of preparing and supporting schools for a social transition (which he does in collaboration with UCT clinical social worker Ron Adinall), there has not been one incidence of significant bullying in the schools that he has worked with.

"Children and adolescents understand and accept gender diversity a lot quicker and better than adults," he notes.

Find our transgender support resources here: Crossing the Divide 

Questioning, curious or exploratory teens

While social transitioning is often the first port of call for pre-pubescent trans kids, it can also be a powerful interim step for questioning teenagers.

"On the LGBTQIA+ spectrum, there's a second 'Q' that stands for 'questioning'," notes Lee-Anne Walker, founder and executive director of trans support nonprofit Be True 2 Me.

According to Walker, most adolescents are clear on their gender, assuming they've had the freedom to interrogate their thoughts and feelings without judgment or prejudice. However, some may still be questioning or unsure about their gender or sexuality, which is also valid.

Irreversible damage?

For trans kids who are sure about their identity, the consensus among gender-affirming medical professionals is that transitioning should ideally happen before Stage 2 of puberty properly sets in.

"The effects of puberty are permanent to the body, and transitioning from that is painful and very expensive," says Walker.

She also points out that puberty can be painful and distressing for a transgender child. "For a trans boy or young man, breast development and getting their period is extremely dysphoric and foreign to the body. If parents see that kind of distress in their child, they will want to take action on it as soon as their child is ready," she says.

Tomson highlights most parents' concern that hormone replacement therapy has irreversible consequences. As she points out, so does allowing a transgender child to go through puberty as the wrong gender.

"With no intervention, trans girls who are assigned male at birth will go through puberty fueled by testosterone. They will have to contend with irreversibly thickened vocal chords, a deeper voice, and facial hair. All of which take a lot of time and resources to correct if they want to transition. It can generate psychological distress," she says.

The earlier, the better

Pickstone-Taylor notes that if a child is only allowed to transition after they turn 18, it significantly lessens their chances of passing as their identified gender. This impacts significantly on their lives as adults. Transitioning earlier, before puberty takes hold, will eliminate many of these obstacles, enabling trans kids to assimilate seamlessly into society.

"Those who don't pass as the gender they identify as will look like a mixture of male and female, which unfortunately condemns them to a lifetime of abuse from people around them. Complete strangers hurl abuse at them on the streets. Generally well-meaning people become disinhibited and feel they have the right to ask transgender people probing questions, like whether they have a penis or a vagina. They do not get jobs they apply for, as employers do not want someone looking both male and female at a front desk, or anywhere else," he says.

The consequences for trans people who transition after puberty are dire, with studies showing that about 40% of them will attempt suicide – even after treatment – because of the obstacles they face. 

Find our transgender support resources here: Crossing the Divide 

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