Transgender youths

“Trans identity is a complex subject that extends well beyond mere medical or statistical considerations.” Erika Volkmar, of the Agnodice Foundation, which supports transgender and non-binary young people, believes that gender identity should be thought of as encompassing human rights and especially the issue of self-determination. In a transition involving hormonal and physical changes, the hospital operates, prescribes and supports people who believe that the gender they were assigned with at birth does not match the gender they feel they truly are. Occasionally, controversies arise, such as the affair involving Keira Bell, 16, as reported in The Guardian. The young woman is suing the London clinic Tavistock for prescribing her testosterone injections and removing her breasts too quickly. At Lausanne University Hospital (CHUV), gender change requests have increased in the last few years, giving the medical profession a new challenge to grapple with. Should we touch healthy tissue, on young bodies, whereas these individuals’ gender incongruence causes them tremendous distress?

In 2021, the CHUV received 49 requests from young people aged between 18 and 25, compared with seven in 2017. This increase in reassignment surgery requests is difficult to explain. Some experts do not agree that it points to increased gender dysphoria. They feel it has more to do with the fact that a “trans coming out” has become less taboo and is facilitated by greater visibility in the public arena. Until now, trans people who never could have imagined coming out have stuck with simply taking on the style and attitudes of the other sex. Now they know they can officially change their name and possibly even receive hormones and surgery. Consequently, the hospital is trying to figure out the best solutions to respond to these requests in the most appropriate way.

1/ Construction of gender

Medically speaking, we have no definite explanation for why someone feels more like a man or a woman. Psychoanalyst and philosopher Jean Laplanche believes that gender even precedes sex. “We can actually consider that the construction of gender in children starts as early as the musings of their parents, that it is influenced when the parents find out during the prenatal scan whether they’re having a girl or a boy,” says Dana Pamfile, a psychiatrist and psychotherapist from the CHUV who works with trans and gender questioning adults. “Afterwards, the construction of gender identity continues in early interactions, through complex psychological processes of identification with and by the other. Then comes the pivotal stage of puberty, with the development of secondary sex characteristics and sexual orientation, which will also contribute to establishing gender identity and how it evolves. Finally, adults also experience times of questioning how they relate to gender when they become parents, for example.” 

However, these influences only partially explain why gender incongruence occurs, sometimes as early as the age of 3 or 4. The World Professional Association for Transgender Health, or WPATH, currently serves as the authority on the subject. In a document on the standards of care, it details how trans identity manifests itself in young children, noting that it rarely persists into adolescence and adulthood, and that it often reflects explorations that make up their psychological development. It can be expressed verbally, by wishing they belonged to the other sex, or by complaining about their physical characteristics and genital functions. These children may also prefer games, clothes and activities that are typically associated with the other gender. 

The WPATH also states that trans identity emerges when gender expression does not match the characteristics stereotypically associated with one’s sex. This phenomenon “should not be judged as inherently pathological or negative”, the statement reads. “People who do not feel that they fit into the gender assigned to them at birth do not necessarily suffer,” Dana Pamfile says. “It’s only when suffering becomes clinically significant and psychological disorders such as anxiety or depression develop because of this incongruence that we can talk about gender dysphoria. It’s important to note that not all of these people want hormonal and surgical reassignment treatment.”

If a young child is diagnosed with gender dysphoria, psychological and family counselling can be offered to monitor its development and support the child through the transformations of puberty. The child may also change gender within the family and socially, i.e. ask to be called by a first name and pronoun in line with the felt gender. “The danger would be to follow a predetermined path,” says Mathilde Morisod Harari, chief of the CHUV’s paediatric liaison psychiatry unit. “Each situation is different. As health professionals, we need to understand what is at stake in these types of requests. Sometimes the situation is very clear, sometimes the young patient needs more time and support to understand their story. The most urgent priority is to listen to and recognise the individual’s request.” 
 

2/ A critical period

Pre-adolescence is a time of great transformation for transgender people. The onset of secondary sex characteristics – body hair, breasts, voice change – can be unbearable at this point if these signs do not align with the person’s perceived gender identity. Like other countries, Switzerland has noted an increase in recent years in the number of treatment requests from people aged 18 to 25. In 2017, the CHUV received seven patients in this age group, consisting of 1 trans woman and 6 trans men. In 2021, 20 trans women and 29 trans men submitted treatment requests. People who identify as non-binary also consult, but very sporadically. The patient care services are looking for the best solutions to alleviate the pain that these youths are experiencing. “It's not easy. We must deal with an often urgent request from the person, while our internal protocols lay down a multidisciplinary approach and therefore require us to take our time in treating these individuals,” says Nelly Pitteloud, professor and chief of the Service of Endocrinology at the CHUV. “For example, I refuse to see a young patient who is not getting psychiatric treatment.” For Lucas, a 15-year-old trans male, his breasts are the main obstacle to his well-being. Although he doesn’t want to take testosterone for now, he is looking forward to his 16th birthday so that he can have his breasts removed. “I take my shower in the dark, or with my phone to watch videos so I don’t have to think about it. My breasts have always bothered me. During the day, I mask them with a binder – a sort of corset – and wear baggy black clothes.” 

To stop the development of these secondary sex characteristics, young transgender people can be administered puberty blockers. This solution is still being discussed by the medical staff. “What we really need are studies on the subject,” says Nelly Pitteloud. “There are studies for adults, but not for young people. We have very little experience with the effects of these treatments on bodies that are still growing at the beginning of puberty.” Hormone blockers can be prescribed at stage 2 or 3 in the Tanner stages of puberty development. In other words, when puberty has barely begun. The testicles and penis have grown slightly, or the breast bud has appeared and the areola is beginning to enlarge. “Hormone blockers are taken under medical supervision,” says Kanetee Busiah, a paediatric endocrinologist at the CHUV. “Testosterone and oestrogen play an important role in overall development, including bone maturation.” The young person should therefore have a medical exam every three to six months when taking hormone blockers.

The hospital is moving in this direction, trying to support people who want to depathologise their transition but have difficulty achieving it without medical help. “If we respond immediately to the request of some young people without taking the time to properly assess their situation, it can be dangerous, because once hormones are taken or an operation is performed, it’s difficult, if not impossible, to go back,” Mathilde Morisod Harari says. Gender dysphoria, which until last year was classified as a mental disorder, is now considered a sexual health issue. In Switzerland, a certificate of gender dysphoria issued by a psychiatrist is needed to be covered by the national healthcare system. “A gender dysphoria diagnosis is based on the person’s subjective experience. Making sense of it means revisiting the person’s history to understand how their relationship to gender and sex has been forged,” says psychiatrist Dana Pamfile. It is also to make sure that transgender identity is not the symptom of an illness. “Adolescence is a time when mental disorders can crystallise. In rare cases, gender dysphoria is the initial stage of psychosis or dysmorphophobia, for example.” In these situations, the first step is to treat or stabilise the underlying disorder and observe whether the gender incongruence persists before moving into body modification treatments. 
 

Recommendations for assessing gender dysphoria from the standards of care published by the WPATH include consideration for social and family support. “This factor is of key importance in the well-being of trans people, especially during their transition,” says Dana Pamfile. But this can be difficult for friends and family, who do not necessarily know where to go, how to talk about it, or how to support the person undergoing transition. “The subject was not totally new to me, but spontaneously I didn’t know which organisations to go to for help,” says Sarah, Lucas’s mother. “I ended up doing some research and shared what I found with my son. Then I let him choose where he was most comfortable going.” At school, Lucas’s transition is very poorly accepted. The teaching staff at the private institution where he is enrolled refuses to call him by the first name and pronoun he wants. “One time Lucas came home from school with a bloody face. The anguish he was going through was so intense that he’d done it to himself. I support him, of course, but it’s not easy every day.”

In pre-adolescence, a young transgender person has a mission to prepare, together with family and medical staff for the transition to adolescence then adulthood, when hormonal and surgical transition options open up to them. To give the individual complete freedom of choice, physicians must make sure that the young person is fully capable of discernment.

3/ The art of deciding for oneself

Informed consent is when the young individual can make their own choices. This means that the innermost perception of the person concerned is the deciding factor. However, even though the medical profession should not get involved in gender determination, it plays a crucial role in providing information on gender transition and issues revolving around it. Fertility planning is one of them and is a key point. Before starting any treatment, either hormonal or surgical, an individual must make a choice whether or not to preserve gametes. “It’s not easy to imagine yourself as a parent at age 15,” says Mathilde Morisod Harari, chief of the paediatric liaison psychiatry unit at the CHUV. “The problem is that at 15, young people rarely want children. With the people we see, the question of parenthood is often overshadowed by the urgency they feel to start hormonal treatment. Currently, few people ask to preserve their gametes.” However, collecting and preserving sperm and eggs is not a new procedure. Medical staff does this for children who need extensive treatment, for example cancer cases. For young trans men, dealing with menstruation is another challenge. To keep periods to a minimum, they can take continuous oral contraceptives. 

Once fertility and the consequences of hormone therapy have been clarified, the person can then start treatment, which must be taken regularly, for the rest of their lives. “At the CHUV, we block the endogenous system before administering hormones of the gender to which the person wishes to transition,” says Nelly Pitteloud. Once hormone therapy is under way, it can take three to six months, depending on the dosage, before any effects on the body are visible, and about two years for a complete change. 

The hormones can be administered by injection or in a gel applied to the body for testosterone and as a patch or tablet for oestrogen. “In 70% to 80% of cases, things go extremely well. But for some people, the treatment is not a good experience. That usually happens when their expectations were too high.” When testosterone is being taken to transition from female to male, the size of the clitoris increases, the voice becomes deeper, facial and body hair grows, menstruation stops and the ratio of body fat to muscle mass decreases. In the case of oestrogen intake, for a change from male to female, the breasts gain volume, erectile function can also decline, the ratio of body fat to muscle mass increases. “For female to male transitions, we can induce very similar secondary characteristics, but the reverse is more complex. For example, it’s more difficult to make a deep voice high-pitched.” Also, the characteristics acquired by taking hormones are not all reversible, even if treatment is discontinued. The size of the clitoris and pitch of the voice are irreversible. 

In masculinising hormone therapy, a major step is the mastectomy. The operation involves both removing the person’s breasts and constructing a torso. In Switzerland, it can be performed from the age of 14. Tom’s* mother shares on behalf of her 17-year-old son, who has recently undergone a mastectomy. “Tom’s rejection of his chest was first reported to us by the school nurse. After several months of psychiatric counselling, with Tom we came to the conclusion that a transition was needed. My son started taking low-dose testosterone from the age of 15, and then we began the process of having a torso operation.” Initially scheduled in November 2021, the operation had to be postponed due to the pandemic. “The postponement triggered immense distress for Tom. He had to be hospitalised for 10 days to avoid harming his own life. Now he is alive again. I’ve realised that gender dysphoria is painful every second of their life. There is nothing fun about changing gender.”

Genital surgery is often the last step in the transition and is not always carried out. “More and more often, hormone therapy is enough. This is especially true for trans men, who currently make up the majority of people who come through the CHUV,” says Nelly Pitteloud. However, the issue seems crucial for young people. “You're a boy, so do you have a penis?” people would say to Lucas. Tom’s mother agrees. “The only thing others are interested in is what’s going on below the belt and their sexual orientation.” 

Sex, gender and sexual orientation are, however, quite distinct. A transgender person, like a cisgender person, can be homosexual, heterosexual, or bisexual. These topics are at the heart of the training provided by the Agnodice Foundation, which works to ensure full rights and responsibilities for transgender people. “What we need today is training,” says Adèle Zufferey, co-director of the Foundation. “All healthcare professions should know how to welcome trans people in consultation. These days, professionals often don’t know what they’re doing.” Lucas encounters this type of situation when he goes to the pharmacy to pick up his contraceptive pill. “I'm glad that this kind of action is becoming commonplace.”