Just a few minutes ago I received an email from the director of a university hospital program that is well-known for its work with the transgendered population – everything from counseling to surgery, and with an important research program as well.

What would be YOUR response to his question?

A number of weeks ago, I received an e-mail message from a parent of a young biological male (I will omit the age, but let's say a number of years before the normal onset of puberty) who is described as transgendered...this youngster appears to be living in a family that is part of what I might call the subculture of "transgender affirming" families. As far as I can tell, this youngster showed very early cross-gender behavior and has, more or less, been living as a girl since preschool, with very clear familial and professional support in so doing.

Apart from considering puberty blocking treatment, this parent asked me about the possibility of a bilateral orchidectomy (castration).

So, here is my therapeutic/ethical question: would anyone recommend castrating this youngster? If so, why? If not, why?

I will be sending him my response within a day or two, at most.

I had to think this out a bit, and this is about the best I can for now. If more occurs to me I will add it later.

To start with this is a tough question to answer with out knowing the individual concerned. I think the age of the person is not the issue at all, other than the fact that it does give cause to question all the life long ramifications which any one considering orchiectomy or transition should be thinking seriously about any way. So there is nothing really different there.

If you take age out of the equation, and I think you should if you want to be fair to the individual, the issue ethically speaking becomes fairly straight forward.

The questions I think are most pertinent here are: Is she emotionally mature enough to make this decision? Does she understand that this is permanent and irreversible procedure? Is this what she wants or is it what she thinks her parents and family want from her?

I think one could not proceed ethically without first answering these questions. I feel the classic advice of "Rush Slowly" applies very well in this case. In the mean time there are other non-surgical alternatives to delay the onset of puberty.

To the question of maturity I say that is in not so much about age in years but life experience, thought they do tend to go hand in hand for most. Suffice it to say that self knowledge and emotional maturity are not a finish line that we cross at some specific geographical time in our lives but rather they are the very terrain that we travel through during our lives. As individuals we all travel that path in our own way and at different rates of speed. I believe that while a person maturity is not something that is easily quantified, it can be generally assessed to a sufficient degree.

The second question is about the permanence and ramifications of the procedure. This is a little more straight forward, but again the idea of permanence may be a bit abstract to some one so young.

The third question I think may be the thorniest and most difficult to determine. It is also the one I think is the most important. I think it is interesting to consider the possibility that growing up in a trans-positive family may have the some of the very same drawbacks as growing up in a trans-negative family. Children do generally want to please their parents and they can be the most convincing of actors. How you will ever be able to know with any certainty is beyond me, but I believe you must know before proceeding.

I would proceed cautiously but with an open mind in any case. The person who really counts and that we must listen to is the girl or boy as the case may. Any one else's wishes are secondary at best.

With more and more families dealing with this at the pre-pubescent stage, I'd think there would be some tentative guidelines for how they proceed.

I would think they'd wait on removing anything, because they'd want as much volume as possible in the future when she has vaginoplasty. Without the testicles, the scrotum and penis will shrink more than if they waited (I think).

Have you thought about posting this question on a TG site like Big Closet? http://bigclosetr.us/topshelf/

I'd think you'd get a better response from TG folks than the Eunuch folks.

Batman

I would suggest that the Doctor give him drugs that will suppress his testosterone, for six months to a year assuming he has hit puberty. Also, he would have to live as a female for that time. Make sure the parents are ok with it, and support it...it is one thing for someone to say the parents are in on it, and another to sit down and discuss it with them with out the boy present.

While it would be better in the long run to snip before puberty and hormones kick in, but that is way to young of an age to make such a choice...especially one that will affect the rest of the life. If he has gone through puberty then he should go to a sperm back and put some away just in case a change of mind occurs at a later date. Perhaps if he spent some time living with some understanding straight men or very butch gay men (a month or two at least) that might help him out. (no offense against effeminate gay/straight men but that would just further confuse the young man.)

There is also the notion of what will the kids at school say? The bullies will have a field day and everyone else will just ignore him.

This is a tough situation. My first thought is would the child be able to make a more informed choice for themselves after the start of puberty and knowing the effects of testosterone to their system? Of course would this be cruel if she did completely identify as female? The child prepuberty identifies as a female but are we sure she will continue to do so after a natural start of puberty?

My opinion is to let the child start puberty with the support system they have in place. They will surely know if this is too much for the child and can intervene at that point. Having been male and now a eunuch I am glad to know both sides of life.

I know in other parts of the world like Thailand this would be done without question but here, I dont think we as a nation are ready for this. To many red necks, right wing christians, etc. I just dont know, part of me says yes and the other screams no, this is one I am glad I dont have to make.

River

I think the best option here would be to delay puberty, say until about they are 14-16. It would serve two purposes, one it would delay the onset of puberty in the wrong gender, which for most tg can be a horrible experience, aand would give the child time to make sure they are aware of what they are doing is right. I don't think many children under the age of puberty are very aware of their sexuality, so letting them go through puberty of their choice would reaffirm their choice.

There would also be some concerns for the child going through school such as physical-ed classes, but I'm sure the parents and doctors could work out solutions to that.

I am going to assume that this person does indeed have a true identity of female and refer to her using female identifiers throughout my answer.

I have to agree that it is difficult to formulate a certain answer without knowing the girl personally. When it comes to something like transgender transition, what is right for one person is completely subjective.

While regrets among transitioning adults do not seem to be uncommon, especially when the gender conflict first appeared past puberty, it seems that regrets among people who complete transition and first had a serious discomfort with their birth gender at a very early age are extremely rare. If this girl has

JesusA (imported) wrote: Tue Dec 11, 2007 10:12 pm been living as a girl since preschool

and showed cross-gender behavior from an even earlier age, I have serious doubts that she would ever regret her decision to transition.

Nonetheless, there are always those rare cases, and the possibility of regret cannot completely be ruled out.

I would want to know who actually came up with the idea of castration? Was it the girl or her parents? If it was her parents, does the girl actually want this? Does she understand what castration is?

I think that we need to be sure the girl understands the irreversible nature of castration, as well as the function of the testicles. Does she understand that without them she will never be able to obtain normal manhood? Does she understand that she will never be able to have biological children?

I also think we need to understand her feelings about her penis. It has been shown that transgender people who express outright hatred for their penises are less likely to have regrets than those who are simply indifferent, and especially those who actually enjoy their penises and associated functions.

I think there is another important factor that we cannot overlook. I have read the stories of many transgender adults, and I have never come across one who would not have given anything to have been able to experience a normal puberty in the gender they identify as. I hesitate to think how this girl would react if she were to one day discover she had the opportunity to experience a female puberty but was turned down because we were afraid she might regret it.

So we have a few different options to look at here, and looking at each one and discussing it with the parents and the girl is best before making a final choice.

Option one is allowing her to experience the start of male puberty, and this is the option that has been traditionally recommend by professionals in the community. From a logical, rational point of view it certainly makes sense. It would give her the opportunity to see how her body would start to develop in her birth sex, and if she finds it distressing, that would only further confirm her female identity. The primary disadvantage here would be the irrversible breaking of her voice, which usually occurs quite early on in male puberty. While male voices can be trained to somewhat resemble female voices, the results are usually less than pleasing.

But from a humane point of view, does it really make as much sense as it seems? If the girl has had a strong female identification since very early childhood and has even lived as a girl since then with no issues, then might we already be certain enough that any degree of male puberty would be unbearable for her? We don't take "ordinary" girls and give them testosterone so they can "see what a male puberty would be like", so why should we do this with her simply because she had the misfortune of being born into a male body?

Option two would be to administer drugs that will block the onset of male puberty. From a logical viewpoint, this is the option that probably makes the most sense. She will prevent the masculinizing effects of a male puberty, and at the same time avoid doing anything irreversible while she confirms her identity as her cognitive reasoning abilities improve with age. It is also a reasonably humane option, because although she is not getting to undergo a female puberty at a normal age, she is still not being forced to endure a male puberty and the irrversible effects it entails.

The disadvantages to this option are the costs involved. I have never heard of Androcur or Spironolactone being administered for the purpose of blocking male puberty, and it is doubtful that they would be effective enough anyway without the co-administration of high does of estrogen. The only drug that seems to be used for this purpose is Lupron. Lupron is by far the most effective method of blocking gonadal hormones, but it is also by far the most expensive. It is probably one of the most expensive drugs in general, and it is certainly far out of the reach of most families. Now if the clinic were willing to provide the Lupron, then obviously cost would not be an issue. But it certainly will not be insurance paying for it, because most insurances refuse coverage outright, and the few that do cover it have a very narrow, well-defined set of conditions they will cover it for (and being transgender is not one of them).

Option three would be to perform the castration, and then it could be determined whether to include female hormones at the onset of puberty or wait until later on. From a logical viewpoint, this is the simplest method. We basically eliminate male puberty from occuring without the needed for any expensive, potentially dangerous drugs. From a humane viewpoint it is also the best choice if she does indeed have a female identity, especially if female hormones are included at the onset of normal puberty. But this is also the option that would be the most devastating if the girl changes her mind. Her only option at that point would be to take artificial testosterone, which most of us have found is inferior to natural testosterone. She would also have to deal with whatever irreversible effects of female puberty she has experienced, depending on how far she progressed.

Option four is to require to her to experience a full male puberty and wait until adulthood to make the choice to transition. This option I consider to be the least humane as well as the least logical. Aside from the emotional torment she will have to endure if her identity is truly female, which is highly likely to be the case, there is also the issue of the effects of male puberty. There are three that are most troublesome due to their irreversibility without painful and/or expensive procedures: facial hair, masculinization of bone structure, particularly of the face, and voice. We have already discussed voice elsewhere, but facial hair and a masculine facial structure are for many transgender women the two reasons they will never be accepted as ordinary women. To reverse these is quite expensive in the case of facial structure, and both expensive and painful in the case of facial hair. But if she does not reverse these, then she will likely never be accepted as fully female by most of society. In this case we have failed to allow her to live life as her normal self and forced her to have to deal with the same struggles as any other transgender person, struggles which lead to mental illness, drug abuse, and not uncommonly suicide, when we had the chance to prevent them.

The best way to decide which of these options is the best for everyone involved is to include everyone. The girl, the parents, and the clinician need to make this choice together.

As for my recommendation? Well, my personal recommendation would be to go for it, and also administer female hormones. This is because I find it highly unlikely she will ever regret her decision, and because most transgender adults who have had these feelings from such an early age would have given anything to be castrated before puberty and experience puberty as the gender they identify with.

But in my more "professional" judgement, I am going to have to agree with many others and say that option two is best, the administering of drugs to delay puberty and give her more time to be sure. This option I think is the best balance between being humane and being logical.

At the center of this distressing question is another question. Do we trust the word of our children? Most times it seems the feelings of a child are called into disbelief and then overruled or simply discarded as an example of "she doesn't know enough to tell us her real needs". I believe such an attitude does a disservice to our children. Children may lack experience of the world, but they do not lack experience of themselves. A more pertinent inquiry might be: what is the influence of the adults surrounding the child? The larger hazzard is that the adults are influencing the child's feelings by transfering their wishes for her onto her thoughts. I don't suggest that they are bending her mind for some dishonest purpose, only that adults can have a very persusive, if unconscious, influence on the youngsters that admire them. With the influence of the involved adults accounted for and a responsible party observing, I think we can believe the child when she says "I am not a boy. Help me." --FLO--

As happy as I would be to have mine gone, I do not think ANYONE (Even a parent) has the right to make this decision for another. A child, and he is a child, does not have the maturity nor comprehension skills required to consent to such a drastic and permanent change.

Just yesterday we had an 18 year old pretending to be 26 so he would be taken seriously by the membership here. I often see new young members cautioned by older (wiser?) members to be patient and to wait a few years.

As an aside, I know and have had "relations" with several Trans-men. F2M TG's who would absolutely LOVE to have a dick. But in all three cases they have made a complete outer transition including mastectomy, without modification to their genitals. For all three the reason is the same, they want to enjoy orgasm. And such surgery would most certain limit their capacity to reach climax. All humans have the right to enjoy sex. Lots of M2F TG's keep their dicks so they can enjoy sex. Sure, most WISH they had vaginas, but accept where they are so they can enjoy all the fruits of interpersonal relations.

Sex is a HUGE part of the human condition. And as such only the individual, with an informed and competent knowledge of the matter, should be allowed to control this type of surgery.