Treatment of transgender youngsters: Case Study 2

A 16½ year old individual, who commenced the transition from a male to a female gender role, wrote separate letters to the two clinicians responsible for her care, shortly after being provided with medication to block the production of testosterone.

Letter to a consultant paediatric endocrinologist

Thank you for your letter dated 1 February and for the speed with which you responded to my letter of 27 January.

Thank you, also, for clarifying that the effectiveness of the drug (hormone blocker) will be difficult to measure until I have received at least 3 injections.

I do have some further questions, however. I will mark, in bold, which specific (as opposed to rhetorical) questions I would like you to answer, please.

You say that measuring my hormone levels won’t help as it’s what I’m feeling and what is happening in my body that’s important. I am confused by your next statement; you say that hormone replacement therapy cannot commence until my testosterone production is fully suppressed – without measuring hormone levels, how would we know when testosterone suppression is being/has been achieved?

You go on to say that you would normally give a period of around twelve months blocking treatment before adding any oestrogen – why is this, for someone of my age and maturity, when hormone neutrality can be achieved within twelve weeks? Also, is not each person that you see different from another? How can there possibly be a ‘one rule fits all’ approach in this type of medicine?

The Specific Endocrinological Recommendations, contained in the Guidelines for the management of Gender Identity Disorder in Adolescents and Children (published by the British Society of Paediatric Endocrinology and Diabetes), states that blocking treatment should be kept to a minimum period, with twelve months being the maximum. There doesn’t appear to be any hard and fast rule there, except for the recommended maximum period of twelve months.

I am not a young teenager; I am a sixteen year old who is, as a result of my life experience to date, mature for my age. For any other necessary drug treatment (and believe me, this is absolutely and utterly necessary), I am of an age where I could give my informed consent – why is this apparently not the case here?

By the way, just to comment on the Endocrinological Recommendations, I believe that the people who wrote them have very little, or a very misguided, understanding of my condition. I wonder if a Consultant Psychologist/Psychiatrist, specialising in GID, was consulted as part of the process of putting the Recommendations together. I suspect not and so I suggest that these Recommendations should form only a part of the whole treatment guidance, in conjunction with the Harry Benjamin Standards of Care.

The Harry Benjamin guidelines do allow professionals flexibility in the way that they treat people for this condition; perhaps this is because Mr Benjamin understood that every person is different and should be treated as an individual. It seems, though, that, in the case of the Portman Clinic, the Endocrinological Recommendations override the Harry Benjamin guidelines. This cannot be right – surely the necessary endocrinological intervention, to help to alleviate the distress of this condition, should be directed by the mental health professional involved, as per the HB guidelines, and not the endocrinologists? I will be writing to the Consultant Child and Adolescent Psychiatrist who has been handling my case in the near future to try to get some clarification on this very important issue.

I understand, of course, that there are physical risks with any hormonal intervention, but I am asking you to understand that the mental torture and emotional agony, caused by not providing intervention at a suitable time, is for me, far, far worse than the thought that I might not live as long as the average person.

If I could have started on blockers at Tanner Stage Two (this, for me, was at the age of about twelve), which is permitted by the Harry Benjamin guidelines, I would have been able to avoid the worst physical effects of male puberty; as it is, I am going to have to spend years, and a lot of money, trying to get rid of the many physical male attributes that I could have avoided. In fact, in respect of permanent hair removal, I am told that I cannot start on this long and painful process until all puberty processes are completed. So, if the feminising hormones take two years to complete the female puberty that you say is necessary, I still have many years of being covered, from head to toe, with thick, black hair to look forward to.

I have, unfortunately, and as the current Recommendations require, experienced the distressing full effects of male puberty, including all of the secondary characteristics; I actually began my puberty at the age of ten, so I have lived with this profound physical wrongness for over six and a half years. The last two and a half years have been horrendous for me, with my body becoming so disgustingly adult male that I cannot bear it. Imagine how you would feel if, tomorrow morning, you were to wake up to find yourself in an male body, with a man’s voice and a man’s face looking back at you from the mirror, with early morning beard and moustache stubble, with no breasts, an adam’s apple, large male feet and hands, a body covered in thick, black hair and a penis and testicles.

Please, just take time out to consider how you think that would make you feel. Do you think that it would it be a terrible thing to happen to you? Do you think that you’d feel as if you were going crazy? Would your brain be screaming out, in protest, that you are female, not male? Well, welcome to my world. This terrible thing has happened to me and it is worse than you could ever imagine. I wouldn’t wish it on my worst enemy, although, if I’m honest, I would like you, and all professionals who deal with transsexual people, to live in my shoes for a day or two, just so you could understand what living with this horrific condition is really like.

Please listen to me when I tell you that I have no conflicting feelings whatsoever about my gender – I am female. Living in a male body hurts beyond belief. I sometimes feel as if I will go crazy with the sadness and desperateness of it. My body will never, ever be as I would like it to be and now, unfortunately, it is really a case of damage limitation. All I want is to be able to get on with my life as a female; at the moment, I am living in a limbo land – I have a female name and I dress in female clothes, but I have facial and body hair, which makes me feel horrible, I am the wrong shape for the clothes that I wear and I have genitalia which is completely alien and upsetting and which protrudes through my clothes. Female hormones are merely the first step along a long medical road that I must follow.

My school has been great about supporting me and many of the pupils are kind and understanding. Many, though, are ignorant and cruel and they shout out things like, ‘Girl with a cock’, ‘There’s the he/she/it”, ‘Tranny boy’, and other names. On my way to school, people shout similar comments from their cars, because of the way I look. I want this school to be the last place that this happens to me. When I leave school, to go to University, or to get a job, I want to be able to keep my private life private; this is nobody else’s business. My being abused and discriminated against can be avoided, or at least curtailed, by my having been on female hormones for 9 months by the time I leave sixth form and by my being able to at least ‘look the part’. This does not seem to be too big a thing to ask.

If I could be, I would be on female hormones now – I have not taken the internet route because I want my treatment to be carried out safely and by people who know what they are doing. I am willing to remain on blockers for a total of eight months, if the system says that I must. However, I do not feel that my request to start feminising hormone therapy in September is unreasonable, for the reasons I have stated both in this letter and in my last letter. In fact, I believe that to withhold feminising hormones at the age of seventeen and three months, is, in my particular case, needless and cruel.

When I met with the Child and Adolescent Psychologist on 7th February, I was assured that there is flexibility in the system and that the Portman Clinic does treat each person as an individual. With this in mind, I ask, please, that you and your colleagues remain open-minded and flexible with regard to my treatment and that, rather than looking at my treatment from only one, endocrinological, viewpoint, you take a more holistic approach, as per the Harry Benjamin Standards of Care.

The Child and Adolescent Psychologist said that she would arrange for us to meet at the March clinic, for a progress/monitoring meeting although I haven’t heard from her regarding this. Perhaps you could write back to me with a date and time for the meeting and to answer my questions?

I look forward to hearing from you.

With best wishes and kindest regards

Letter to a consultant child and adolescent psychiatrist

I have attached a copy of my letter to the Consultant Paediatric Endocrinologist, for your information.

Since you are a Consultant Psychiatrist, rather than an endocrinologist, I am interested to hear your response to the same questions that I asked in the attached letter, if you wouldn’t mind. I have put my specific questions in bold type.

  1. I am not a young teenager; I am a sixteen year old who is, as a result of my life experience to date, mature for my age. For any other necessary drug treatment (and believe me, this is absolutely and utterly necessary), I am of an age where I could give my informed consent – why is this apparently not the case here?
  2. The Harry Benjamin guidelines do allow professionals flexibility in the way that they treat people for this condition; perhaps this is because Mr Benjamin understood that every person is different and should be treated as an individual. It seems, though, that, in the case of the Portman Clinic, the Endocrinological Recommendations override the Harry Benjamin guidelines. This cannot be right – surely the necessary endocrinological intervention, to help to alleviate the distress of this condition, should be directed by the mental health professional involved, as per the HB guidelines, and not the endocrinologists? Please would you clarify exactly what guidelines the team at the Portman adheres to – surely it cannot be the endocrinological recommendations alone? If it is, how can this possible allow for the flexibility that the Child and Adolescent Psychologist tells me is permitted within the system?
  3. My school has been great about supporting me and many of the pupils are kind and understanding. Many, though, are ignorant and cruel and they shout out things like, ‘Girl with a cock’, ‘There’s the he/she/it’, ‘Tranny boy‘, and other names. On my way to school, people shout similar comments from their cars, because of the way I look. I want this school to be the last place that this happens to me. When I leave school, to go to University, or to get a job, I want to be able to keep my private life private; this is nobody else’s business. My being abused and discriminated against can be avoided, or at least curtailed, by my having been on female hormones for 9 months by the time I leave sixth form and by my being able to at least ‘look the part’ as far as possible. This does not seem to be too big a thing to ask; if it is, why is it?
  4. If I could be, I would be on female hormones now – I have not taken the internet route because I want my treatment to be carried out safely and by people who know what they are doing. I am willing to remain on blockers for a total of eight months, if the system says that I must. However, I do not feel that my request to start feminising hormone therapy in September, when I will have been on the blocker for 8 months, is unreasonable, for the reasons I have stated both in this letter and in my last letter. In fact, I believe that to withhold feminising hormones at the age of seventeen and three months, is, in my particular case, needless and cruel – what is your view on this?
  5. When I met with the Child and Adolescent Psychologist on 7th February, I was assured that there is flexibility in the system and that the Portman Clinic does treat each person as an individual. With this in mind, I ask, please, that you and your colleagues remain open-minded and flexible with regard to my treatment and that, rather than looking at my treatment from only one, endocrinological, viewpoint, you take a more holistic approach, as per the Harry Benjamin Standards of Care.

Is what the Child and Adolescent Psychologist says regarding flexibility and treating people as individuals true for all the members of the Portman team treating me?

Are people really given treatment that is tailored to their individual needs or, as it appears to me, do the endocrinologists actually dictate what treatment can be given and when?

If the latter is the case, how can this possibly be right and how can you, in the light of the revised Harry Benjamin Standards of Care, permit it to happen?

I am honestly not trying to be a pain in the neck or to cause trouble or upset; I am just trying to understand what is going on and why my pleadings to be heard seem to be falling on deaf ears.

Thank you for listening to me and I look forward to hearing from you soon.

Yours sincerely

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