Transition-Related Care and Youth: A Prologue

Alongside the recent increase in interest in trans issues has come a renewed discussion among professionals about access to transition-related care for trans minors. The three primary forms of transition-related care for trans minors are puberty blockers, hormone replacement therapy, and genital reassignment surgery. Oftentimes, they are allowed fairly late. For example, surgeons doing genital reassignment surgery typically require the patients to have reached the age of majority, which many a trans person feels to be excessive.

Understanding what each does is essential if we are to have a discussion about lowering the age of access to those procedures. I will summarily explain each of the three, as well as sketch the process for obtaining them for adults under the current system.

Puberty blockers are a range of medications, some of which are hormones, which prevent minors from undergoing puberty. They serve to prevent the formation of dysphoria-inducing features — for instance breasts for transmasculine individuals, and facial hair for transfeminine individuals — which gives the child more time to decide which hormonal regimen they want to undergo. The World Professional Association for Transgender Health — also known as WPATH — recommends reaching Tanner Stage 2, which is the second stage of puberty out of five, prior to taking puberty blockers. Children can reach Tanner Stage 2 as early as 9 years old, and fairly frequently reach at least Stage 3 before being allowed to go on blockers.

Hormone replacement therapy is a hormonal regimen allowing the person to undergo a puberty concordant with their gender identity. For transmasculine children, this consists in testosterone and, more rarely, antiestrogens. Transfeminine minors will instead have a regiment consisting of anti-androgens and oestrogens. Under the current practices, trans minors may rarely begin hormone replacement therapy before 16 years of age, despite the fact that most of their peers will have completely puberty by that age.

For adults, obtaining hormone replacement therapy normally involves seeking a referral to an endocrinologist, who will then require the patient to get a letter from a mental health professional who can attest to the person’s persistent and well-documented gender dysphoria. The cost of therapy as well as the rarity of mental health professionals comfortable with issues of gender identity can be significant barriers to access. For this reason, as well as movements towards the depathologisation of trans bodies, a number of physicians and clinics have moved towards an informed consent model of prescribing hormone replacement therapy. Under the informed consent model, no letter from a mental health professional is required unless the physician suspects that some mental health issues are not reasonably well-controlled. Instead, the patient will be given an explanation of potential side effects in both oral and written format, and will be made to sign an informed consent form prior to getting the prescription. McGill University Health Services, for example, has made efforts to move towards an informed consent model. Informed consent models, at least for adults, have been a well-appreciated development in trans communities.

Genital reassignment surgery is but one of many non-hormonal treatments that are frequently desired by trans people. However, since most other treatments — such as mastectomies and facial feminisation surgery — are unnecessary for individuals who have taken puberty blockers, I will not describe them at length.

Genital reassignment surgery is the name given for a range of procedures such as vaginoplasties — the shaping of a vagina from a penile base — or phalloplasties — the construction of a penis from the person’s clitoris and an external graft site, oftentimes the forearm.

Under the current WPATH guidelines, only people having reached the age of majority can elect to have genital reassignment surgery. Beyond being required by surgeons, those guidelines are also frequently followed by insurers, as is the case in Quebec.

The process for having genital reassignment surgery is long and expensive. I know firsthand. We see here how thin the barrier between academia and personal life is for trans activists, and you will now know way more about my life than I’d normally be comfortable with. First, one must show presence of persistent and well-documented gender dysphoria. Significant health and mental health concerns, if any, need to be under control. One must also have been on hormone replacement therapy for at least one year and, more controversially, have lived for one year “in a gender role concordant with one’s gender identity”. For trans women, that means living “as a woman” — whatever that means, and “as a man” for trans men.

Having had access to education and to various leading trans activists, the first step of figuring what the hell to do was the easiest in my case. I just looked up the standards of care and read them. To begin the process, I went to see my family physician. So far so good. I am lucky: my physician is one of the rare specialists in trans healthcare in Quebec and is comfortable prescribing hormones on her own. Her waitlist is unfortunately over eight months long, which is still shorter than many other specialists. Anyway, since she is both my physician and hormone prescriber, I got my first two letters — attesting to my general state of health as well as how long I have been on hormones quite easily.

Now the harder part: finding two mental health professionals who can attest to my “persistent and well-documented gender dysphoria”. It may come as a surprise, but talking about my feelings towards my genitalia for a few hours with a sixty year old cis man who comments on my looks and tells me that if he didn’t know me he totally wouldn’t guess I’m trans — and also something about bathrooms and urinals, I don’t really remember clearly — isn’t my idea of a good time. Paying 320$ for it is just the cherry on top. My partner, friend Jill, and sister can all attest to how much I loooooooooooved those few therapy sessions.

But a girl’s gotta do what a girl’s gotta do, and all younger female psychologists — whom are usually less creepy and put me more at ease — weren’t taking on new clients.

That was the second letter. The first mental health letter was both easier and harder to get. Easier, because it didn’t cost me anything, because I knew the therapist — she is very nice — and because I got an appointment rather quickly. Harder, because it required being a McGill student, because she had no previous experience writing those letters, and because she probably wouldn’t have felt comfortable writing the letter had she not been following me for semi-related reasons for over a year. My example just goes to show how far sufficient good will and readiness to learn can go, if you are lucky enough to find someone who’s ready to put in the work. Unfortunately, my situation was rather exceptional, and for most people getting this letter will be difficult and expensive.

Letter in hand, form filled, I sent all that to the surgical centre. That was over four months ago. I’ve yet to hear back from it. It’ll probably take another whole year before I undergo surgery.

There is nothing rushed about either the process, which takes a very long time or the decision to undergo surgery — which was one of the biggest and most emotionally difficult decisions I’ve ever made in my life. Is it really necessary to further delay people’s transition — treatments deemed medically necessary by professionals and shown to have a strong impact on well-being — on account of their being under 18 years old, when so many barriers to access were already erected?

Introduction to the panel “Hormone Therapy & Gender Confirmation Surgery: Access for Youth” hosted by the McGill Journal of Law and Health on April 3rd, 2017 at McGill University.