PEDIATRIC NURSING/January-February 2010/Vol. 36/No.

1 53
Pediatric Ethics, I s s u e s , & C o m m e n t a ry focuses on
exploring the interface between ethics and issues in
clinical practice. If you have suggested topics or cases
for consideration in the column, please contact Anita J.
C a t l i n , D N S c , F N P, FA A N , at catlin@sonoma.edu
Anita J. Catlin, DNSc, FNP, FA A N
Pediatric Ethics, Issues, &Commentary
This article is the first in a three-part series describing the nursing and medical care of a child wishing to change genders.
Part I will depict the psychological and hormonal treatment for children who express a desire to change genders. Part II will
describe surgical treatments and nursing care for gender reassignment from female to male. Part III will present the surgical
needs of transition from male to female.
Hot Topic! What do you think? Send your comments about this topic to pnjrnl@ajj.com. This article discusses a sensitive issue
that is complex and provocative, and will undoubtedly stimulate a variety of opinions. The opinions and assertions contained here-
in are the private views of the contributors and do not necessarily reflect the views of Pediatric Nursing or the publisher.
I
n May 2007, Barbara Walters aired a television pro g r a m
on 2 0 / 2 0 called My Secret Self. This program, still
available in five parts on Yo u Tube, depicts the lives of
two young children who from birth informed their par-
ents that they had the wrong genitalia for the gender that
they were. Both Jesica and Riley, born with male extern a l
genitalia, were by two years old choosing to dress and live
as girls. They clearly told their parents that God had made
a mistake and that they were girl children. Another 16-
y e a r-old adolescent on the show, born as a girl, at 14 wro t e
his parents a letter and told them that he was absolutely in
the wrong body and planned to begin to live as the young
man that he was. Barbara Walters interviewed these chil-
d ren and their parents with dignity. The Walters special is a
good accompaniment to this series of articles, which will
i n f o rmthe readers of Pediatric Nursing on the heath care
needs of the transgender child. This thre e - p a rt series will
C a re of the Child with the Desire
To Change Gender Part I
Bethany Gibson, Anita J. Catlin
discuss the current status of the transgender child and hor-
monal treatments used to suppress and transition gender.
P a rts II and III will discuss transgender surgeries and the
b a rriers transgender individuals face in obtaining health
c a re .
The Condition
Transgender is an umbrella term that literally means
to cross gender lines (Selekman, 2007). These childre n
describe feeling trapped in the wrong body and born with
the wrong genitalia. They may choose to have surg e ry to
remove organs related to one gender and constructed to
resemble the other. The term gender identity disorder (GID)
is the diagnostic category used to describe these children by
the American Psychiatric Association, diagnostic code
302.2. To meet this diagnostic code, there are four compo-
nents to GID or dysphoria.
T h e re must be persistent other gender identification:
the desire to be or the insistence that one is of the other
s e x .
T h e re must be evidence of persistent discomfort about
o n e s assigned sex or a sense of inappropriateness in the
gender role of that sex.
The individual must not have a concurrent physical
intersex condition (such as androgen insensitivity syn-
d rome or congenital adrenal hyperplasia).
T h e re must be evidence of clinically significant distre s s
or impairment in social, occupational, or other impor-
tant areas of functioning.
B e t h a ny Gibson, B S N , is a Registered Nurse, Hospice Case Manager,
and Research Assistant.
Anita J. C a t l i n , D N S c , F N P, FA A N , is a Pe rinatal Ethicist at Sonoma
State Unive r s i t y, Rohnert Pa rk, CA. You may contact the authors at
c a t l i n @ s o n o m a . e d u
This is Pa rt I of a three-part series on children and yo u n g
adults who desire to live as a gender different from which
t h ey were born . The series depicts the psychosocial, med-
ical, and surgical components of transitioning from one gen-
der to another. The medical and psychosocial issues of tra n s-
gender change are complex, and ethical questions may be
raised by those who would challenge these choices. Pe d i a t ri c
nurses will be best able to care for these patients with awa r e-
ness of the multiple dimensions of these procedures and the
ramifications of caring for these children and their fa m i l i e s.
54 PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1
Pediatric Ethics, Issues, & Commentary
The issue of transgender children is a silent one. Caring
a p p ropriately for the child wishing to change gender and
teaching others about this condition may be more critical
than pediatric nurses know. These children are at risk,
whether by decisions of their own making or in danger
f rom others. Statistics provided by Dean and colleagues
(2000) and printed in the document Lesbian, Gay,
Bisexual, and Tr a n s g e n d e red Youth: An Epidemic of
Homelessness (Ray, 2008, p. 62) show the level of risky
behaviors in these youth (see Figure 1 ).
Psychological Issues for Transgendered
Children
Transgender individuals are often perceived to have
mental illnesses, but re s e a rchers have found no corre l a t i o n
between non-normative gender identification and mental
illness (Shield, 2007). Research has found that individuals
who have consistently expressed cross-sex identification
f rom early childhood (toddler age) onward develop psycho-
logical problems resulting from the pain of pubertal physi-
cal changes, including depression, anorexia, social phobias,
and suicidality (Cohen-Kettenis, Delemarre-van de Waal, &
G o o ren, 2008). Furt h e rm o re, transgender youth fre q u e n t l y
re p o rt verbal and physical harassment, assault, and a lack of
feeling safe at school (Roughgarden, 2004; Shield, 2007).
These children are at risk of bullying and violence fro m
others. An example of this is the death of 14-year- o l d
L a w rence King. King, a gender non-conforming boy who
d ressed as a girl at school, was shot to death in 2008 during
school by a classmate at his California junior high (see
F i g u re 2).
While lethal violence like Lawre n c e s murder is rare ,
anti-LGBT [lesbian, gay, bisexual, transgender] bullying and
harassment are pervasive problems in our schools, and
e ffective responses are crucial to prevent escalation
(Jennings, 2009). In the 2005 National School Climate
S u rv e y, nearly one-fifth (17.6%) of LGBT students re p o rt e d
being physically assaulted at school in the past school year
because of their sexual orientation and over a tenth (11.8%)
Figure 1.
A Summary of Risky Behav i o rs Reported by Trans-Identified Yo u t h
S o u rc e : Used with permission from the National Gay and Lesbian Task Fo r c e.
8 3 %
5 4 %
7 1 %
4 6 %
2 1 %
8 8 %
2 5 %
8 %
3 3 %
7 5 %
2 1 %
2 1 %
7 9 %
9 6 %
7 5 %
1 3 %
1 7 %
6 3 %
9 6 %
8 %
Mental Health and We l l - B e i n g
Thoughts of suicide
Attempted suicide
S exually assaulted or ra p e d
Engaged in sex wo rk
S e l f - mu t i l a t i o n
B o dy Modifications
Engage in body modification
Engage in hormone thera py
R e c e i ved silicone injections
Intend to acquire hormones and/or
undergo surgery in the future
HIV and STIs
R e p o rted being HIV- p o s i t i ve
R e p o rted an STI
R e p o rted no being at risk for HIV
Engaged in unsafe behaviors in the
past year that placed them at ri s k
Alcohol and Substance Use
Alcohol use
Binge dri n k i n g
Illegal drug use
Sold dru g s
In recove ry programs for substance abu s e
S ex under the influence of alcohol
S ex under the influence of illegal dru g s
PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1 55
because of their gender expression. Nearly two-thirds of
LGBT students (64.3%) said they felt unsafe in school
because of their sexual orientation and two-fifths (40.7%)
because of their gender expression (Jennings, 2009). Ken
Jennings, director of the Gay, Lesbian and Straight
Education Network, recommends schools develop policy
and education against bullying related to gender choices.
Responses to Gender Identity
Disorder/Dysphoria
H i s t o r i c a l l y, there have been two philosophical re s p o n s-
es to children who clearly desire to live in the altern a t i v e
g e n d e r. The first response is with acceptance, using mental
and physical health measures to ease the transition, and
waiting to see what develops in the future. Research fro m
the Netherlands re p o rts that some children change their
minds before adolescence and no longer pursue a gender
change. An alternative response is to consider these feelings
as a treatable disease and to attempt to treat the child by
re p rogramming, as depicted by Joseph Nicolosi and col-
leagues at National Association of Research and Therapy of
Homosexuality (NARTH) (http://www. n a rt h . c o m / m e n u s /
o ff i c e r s . h t m l ). D r. Nicolosi has forw a rded the idea of re p a r-
ative therapy, or therapy that will teach children to accept
their birth sex, practice hetero s e x u a l i t y, and reject any
a l t e rnative lifestyle. This article will discuss the first
response of acceptance.
Research
The most prevalent re s e a rch in the area of youth with
GID has been done by re s e a rchers Cohen-Kettenis and col-
leagues in the Netherlands. In 1987, Dr. Peggy Cohen-
Kettenis started the first outpatient clinic in Europe for chil-
d ren and adolescents with gender problems and intersex
conditions. Cohen-Kettenis and colleagues (2008) state that
80% to 95% of prepubescent children with GID will re s o l v e
their GID prior to reaching adolescence. However, accord-
ing to recent re s e a rch, children who continue to experience
GID into adolescence will pursue sex reassignment tre a t-
ment and/or surg e ry (Shield, 2007). There f o re, a lengthy
diagnostic process, including psychological screening and
t h e r a p y, are important for children who express a persistent
gender dysphoria in early childhood. Many believe that
teens who have demonstrated persistent and unwavering
identification with the opposite gender may be helped via
early gender reassignment treatment.
R o u g h g a rden (2004) wrote that gender dysphoria can
occur in early childhood, with treating psychologist
M i l d red Brown re p o rting that 85% of her clients re c o g n i z e d
their gender identity was diff e rent from their physical gen-
der before grade school. Pre p u b e rtal gender dysphoria has
also been documented by Dutch re s e a rcher Gooren (1999).
The majority of transgender panelists at the Nort h e rn
C a l i f o rnia Transgender Health and Wellness Confere n c e
e x p ressed conscious recognition of their gender dysphoria
prior to puberty as well (Gibson, 2008).
Psychological Assistance
Therapy can assist the adolescent who has chosen sex
reassignment in managing and coping with social pro b-
lems, such as peer and/or family conflict, completing devel-
opmental tasks on schedule, and coping with the re s u l t a n t
changes and stresses. Acceptance and understanding of
their true gender identity is of critical importance, and ther-
apy can greatly help with this process as well (Shield, 2007).
Finding clinicians with adequate training, understanding,
and experience can be facilitated through the use of trans-
gender and transsexual re s o u rces, such as online discussion
g roups. Communication with others who have alre a d y
begun treatment can 1) reveal clinicians who are compas-
sionate, experienced, and knowledgeable; 2) provide re f e r-
rals to medical centers that specialize in and/or treat trans-
gender; and 3) direct young people to look for health infor-
mation provided by the World Professional Association for
Transgender Health (WPATH), formerly the Henry
Benjamin International Association for Gender Dysphoria
(HBIGDA).
W PATH (www. w p a t h . o rg) is the oldest interd i s c i p l i n a ry
p rofessional association of this specialty and consists of
over 300 physician, psychologist, social scientist, and legal
p rofessionals involved in re s e a rch and/or clinical practice
dedicated to understanding and treating transsexual or
transgender individuals. The organization published their
sixth version of the S t a n d a rds of Care for Gender Identity
D i s o rd e r s , which outlines their consensus re g a rding the
stepwise psychiatric, psychological, medical and surg i c a l
management of gender dysphorias. The S t a n d a rds of Care for
Gender Identity Disord e r s states that the goal of tre a t m e n t
(psychotherapeutic, endocrine, and surgical) is lasting per-
sonal comfort with the gendered self in order to maximize
overall psychological well-being and self-fulfillment
(Meyer et al., 2006, p. 1). WPATH recommends finding a
mental health professional who has been trained in child-
hood and adolescent developmental psychopathology, has
a masters degree or equivalent in a clinical behavioral sci-
ence field, has special training and competence in the
assessment of DSM-IV and ICD-10 sexual disorders, has
documented and supervised training in psychotherapy, and
has education and experience treating gender issues (Meyer
et al., 2006).
Hormones
Pediatric nurses are aware that all children face social,
emotional, and physical changes as they enter puberty and
adolescence. These changes are difficult for many, and the
usual problems faced by adolescents are compounded for
youth who have chosen to dress as and assume the identi-
ty of an alternative gender. Many transgender childre n
experience great stress as their bodies begin to change in
ways that conflict with their sense of gender identity
(Cohen-Kettenis et al., 2008; Roughgarden, 2004).
Te s t o s t e rone and estrogen cause secondary sexual charac-
teristics to develop. Transgender teens living as boys devel-
op breasts and begin to menstruate, and transgender teens
living as girls have their voices deepen, grow facial hair,
have enlarged Adams apples, and become taller than many
women. In addition, a previously small penis begins to
g row and become capable of erections. Many of these chil-
d ren wish to have something medical and/or perm a n e n t
done to prevent these changes.
I n f o rmed consent laws prevent minors from consenting
to their own medical treatment until the age of 18, which
p revents transgender adolescents from utilizing sex re a s-
signment treatments, such as hormones and sex re a s s i g n-
ment surg e ry, unless they have the consent of a parent or
56 PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1
Pediatric Ethics, Issues, & Commentary
g u a rdian (Shield, 2007). The American Association of
Pediatrics, Committee on Bioethics (1995) issued a policy
statement entitled, Informed Consent, Pare n t a l
P e rmission, and Assent in Pediatric Practice, which states
that pediatric patients should participate in decision mak-
ing commensurate with their development; they should
p rovide assent to care whenever reasonable (p. 314). While
the AAP did not state a particular age at which children are
able to give informed assent or true informed consent, it
should be noted that in the Netherlands, informed consent
for medical pro c e d u res can be given at age 16 without
p a rental consent because it is believed children are able to
understand the risks, benefits, and alternatives of tre a t m e n t
(Cohen-Kettenis et al., 2008). Furt h e rm o re, developmental
psychologist Erik Erickson has theorized that by late adoles-
cence, many young people have successfully navigated
exploration of diff e rent selves and developed a stable iden-
tity for themselves (Shield, 2007).
Pubertal Delay
The primary goals of hormone use for those childre n
who believe they need sex reassignment are twofold. The
first is to eliminate, to the degree possible, the horm o n a l l y
induced sex characteristics of the birth-assigned gender,
and secondly, to induce those of the desired gender
( G o o ren, 1999). Discussion of the first goal, suppression of
the puberty-induced secondary sex characteristics of natal
sex, will be discussed in this section. According to the
Netherlands protocol, adolescents diagnosed with GID who
have suff e red with extreme lifelong gender dysphoria, are
psychologically stable and live in a supportive enviro n-
ment are considered eligible for puberty suppre s s i o n
( D e l e m a rre-van de Waal & Cohen-Kettenis, 2006, p. 132). A
letter of recommendation from a psychiatrist outlining the
a d o l e s c e n t s identifying characteristics, gender and/or other
psychiatric diagnoses, length of psychotherapeutic re l a-
tionship, verification of eligibility criteria for horm o n e
therapy and/or sex reassignment surg e ry, and whether the
client has followed recommendations from the org a n i z a-
tion is re q u i red to initiate endocrine treatment (Meyer et
al., 2006).
The suppression of puberty using gonadotro p i n - re l e a s-
ing hormone analogs (GnRHa) may be prescribed for ado-
lescents aged 12 to 16 years old who have 1) fulfilled the
criteria mentioned above, 2) reached Tanner stage 2 or 3,
and 3) reached pubertal levels of sex hormones (Delemarre -
van de Waal & Cohen-Kettenis, 2006). Early horm o n a l
t reatment can reduce the amount of invasive surgical pro-
c e d u res that may be re q u i red with later sex re a s s i g n m e n t
because irreversible physical development secondary to
p u b e rty can be avoided. Female-to-male transitions might
avoid the need for mastectomy, and male-to-females might
avoid the need for reduction thyroid chondroplasty and
voice modification therapy. Initiating pubertal delay at an
early age will most certainly result in high percentages of
individuals who will more easily pass into the opposite gen-
der role than when treatment commenced well after the
development of secondary sexual characteristics, which
will likely result in better quality of life and perh a p s
d e c reased re p o rts of post-operative re g ret due to poor func-
tioning (Delemarre-van de Waal & Cohen-Kettenis, 2006, p.
1 3 3 ) .
As previously discussed, puberty in the birt h - a s s i g n e d
gender can cause the transgender adolescent significant dis-
t ress and discomfort, potentially leading to many negative
emotional and psychological outcomes. While initial
administration of GnRHa results in increased levels of cir-
culating luteinizing hormone (LH) and follicle-stimulating
h o rmone (FSH), continuous administration results in
d e c reased secretion of LH and FSH from the pituitary gland
to levels of a castrated man or menopausal woman
( S k i d m o re-Roth, 2007). Inhibition of LH and FSH inhibits
the gonadal production of the sex hormones testostero n e
and estrogen. GnRHa administered prior to puberty will
completely prevent pubert y, and when administered after
the start of puberty will halt the pro g ression of pubert y,
e ffectively putting it on hold (Brill & Milazzo, 2008; Cohen-
Kettenis & van Goozen, 1998; Cohen-Kettenis et al., 2008).
Other drugs, such as progestins, antiandrogens (males
only), and luteinizing horm o n e - releasing hormone (LHRH)
agonists, may also be used to suppress the physical changes
of puberty (Cohen-Kettenis & van Goozen, 1998; Cohen-
Kettenis et al., 2008; Gooren, 1999; Meyer et al., 2006).
Patients born as girls will experience a weakening of bre a s t
tissue, which may disappear completely, while those born
as males will have a reduction in testicular volume. If this
t reatment is begun later in pubertal development, changes
such as later stage breast growth in girls and deepening of
the voice and facial hair growth in boys will re c e d e ,
although not completely, while any further pro g ression of
p u b e rty will be halted (Delemarre-van de Waal & Cohen-
Kettenis, 2006).
This treatment is fully reversible, and cessation of the
GnRH analog will result in the adolescent resuming puber-
ty in their birth-assigned gender (Cohen-Kettenis et al.,
2008). Pubertal delay can provide respite for the psychoso-
cial pain of the transgender adolescent while simultaneous-
ly allowing time for the therapist and adolescent to furt h e r
e x p l o re their gender identity and wish for sex re a s s i g n-
ment, contributing to greater diagnostic precision (Cohen-
Kettenis & van Goozen, 1998; Cohen-Kettenis et al., 2008).
This can serve to satisfy any doubts the parents and doctor
may have about proceeding with sex reassignment tre a t-
ment, allow time for parents/family to get counseling and
s u p p o rt as needed, notify and educate school personnel,
and explore the full range of treatment options.
Clinics in Boston, Gent, Oslo, and To ronto, all very
experienced in treating gender dysphoric youth, have
begun providing these interventions and/or re f e rrals prior
to 16 years of age as long as hormonal puberty has pro-
g ressed to at least Tanner stage 2 (Cohen-Kettenis et al.,
2008). Other criteria noted for initiation of GnRHa therapy
include persistent GID since early childhood, exacerbated
GID following early pubertal development, no comorbid
psychiatric issues that impede diagnosis or tre a t m e n t ,
p a rental consent, and a social support network thro u g h o u t
the treatment. Additionally, the adolescent can use this
time to learn about the effects of sex reassignment tre a t-
ment, as well as the social consequences of that course,
including GnRH analogs, cross-sex hormones, and surg e ry
(Cohen-Kettenis et al., 2008).
GnRH analogs have long been used in medical tre a t-
ment of precocious puberty in children, with the exact
same purpose and effect, halting puberty (Skidmore - R o t h ,
2007). GnRH analogs used for pubertal delay include
l e u p rolide (Lupro n

[subcutaneous injection; 50
m c g / k g / d a y, may increase by 10 mcg/kg/day as needed]
and Lupro n

Depot [intramuscular injection; 15 mg every

4 weeks in children more than 37.5 kg or 22.5 mg IM every
PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1 57
3 months]) and histrelin (Suppre l i n

LA and Va n t a s

[ y e a r-
ly subcutaneous implant]) (Milazzo, 2008; Skidmore - R o t h ,
2007). LHRH agonist depot triptorelin is a 3.75 mg intra-
muscular injection given monthly (Skidmore-Roth, 2007)
that has been safely used with good results in Dutch clinics
(Cohen-Ketenis & van Goozen, 1998). Spironolactone (up
to 100 mg twice daily, if tolerated) is a diuretic with antian-
d rogenic pro p e rties that has been used to suppress the
e ffects of testosterone effectively (Gooren, Giltay, & Bunck,
2008; Milazzo, 2008). Cypro t e rone acetate (initial dose of
50 mg twice daily, reduced to 50 mg daily when testos-
t e rone levels are effectively suppressed) is a pro g e s t e ro n e
with antiandrogenic pro p e rties and is the most widely used
d rug for this purpose in Europe (Gooren, 1999; Gooren et
al., 2008). Medro x y p ro g e s t e rone acetate (5 to 10 mg daily)
may be used if cypro t e rone acetate is unavailable, although
it has been found to be less effective (Gooren, 1999; Goore n
et al., 2008). Finasteride (1 mg) is a 5-reductase inhibitor
that can be used as well (Gooren, 1999; Gooren et al.,
2008).
A follow-up protocol has been developed to investigate
the efficacy and safety of GnRHa treatment in adolescents
s u ffering from gender dysphoria. Blood work should be
done prior to the initiation of therapy to establish baseline
levels of gonadotropins and sex hormones, and metabolic
d e t e rminants, including fasting glucose, insulin, choles-
t e rol, high and low-density lipoprotein levels, and re n a l
and hepatic studies. Additionally, anthropomorphic meas-
u rements, such as height, weight, sitting height, hip and
waist circ u m f e rences, and Tanner pubertal stage can be
re c o rded initially and re-evaluated periodically to ensure
n o rmal growth and development. Follow-up pro t o c o l
includes appointments with psychiatrist or psychologist
e v e rythree months and laboratory measurements of factors
described above (Delemarre-van de Waal & Cohen-Kettenis,
2 0 0 6 ) .
Living as the Alternative Gender
The second phase of sex reassignment, following diag-
nosis, consists of the real-life experience (RLE) in the
d e s i red gender role, hormone treatment, and surg e ry
( D e l e m a rre-van de Waal & Cohen-Kettenis, 2006). Many
adolescents who begin sex reassignment therapy early
begin the RLE at this stage, although it is not a re q u i re m e n t
during GnRHa therapy. RLE re q u i res living in the new or
evolving gender role full time so as to gain understanding
of the familial, interpersonal, educational, and legal con-
sequences of changing gender (Delemarre-van de Waal &
Cohen-Kettenis, 2006, p. 133). It is recommended that the
RLE occurs for two years while continuing with education,
employment, or volunteer work, that clients should pro-
vide evidence that others are aware of their new gender
role, and that name and identity document changes are
made during this period (Jain & Bradbeer, 2007; Meyer et
al., 2006).
Cross-Sex Hormone Therapy
The next action for gender transitioning is the second
goal of hormonal therapy induction of the secondary sex
characteristics of the desired gender. The physical changes
to ones outward gender expression necessitates that the
RLE begins at this stage, if the adolescent client has not
a l ready begun living full time in his or her desired gender.
This second stage of physical intervention, cross-sex hor-
mone administration (estrogen or testosterone) induces
those masculinizing or feminizing characteristics, and the
t reatment is considered to be partially re v e r s i b l e
( D e l e m a rre-van de Waal & Cohen-Kettenis, 2006; Meyer et
al., 2006). The HBIGDA S t a n d a rds of Care s e l i g i b i l i t y
re q u i rements include one letter from a mental health pro-
fessional (who has been treating the client for at least six
months) to the physician overseeing medical tre a t m e n t ,
signifying that 1) the mental health clinician will work
closely with the adolescent throughout hormone therapy
and the RLE, 2) that the teen has reached a minimum age
of 16 years, and 3) the teen preferably has consent by the
p a rent or legal guardian, although it is not re q u i red (Meyer
et al., 2006). The physician administering hormonal tre a t-
ment and follow-up monitoring is not re q u i red to be an
endocrinologist, but should be educated in the medical and
psychological aspects of treating individuals with GID. The
patient must have the capacity to understand the risks and
benefits of treatment, have his or her questions answere d ,
and agree to medical monitoring of treatment (Meyer et
al., 2006, p. 17). A written informed consent document is
m a n d a t o ry. It is also recommended that the physician pro-
vides the patient with a written document stating the indi-
vidual is under medical supervision, including horm o n e
t h e r a p y, which the patient can carry at all times to pre v e n t
d i fficulties with the police or other authorities (Meyer et al.,
2006).
A study by Cohen-Kettenis and colleagues (2008) found
that adolescents selected using HBIGDA eligibility re q u i re-
ments and beginning cross-sex hormone therapy between
16 to 18 years of age were no longer suffering from gender
dysphoria and were both psychologically and socially not
v e ry diff e rent from their peers 1 to 5 years after sex re a s-
signment surg e ry. Use of either sex steroid in high doses is
contraindicated with serious liver disease, poorly contro l l e d
diabetes mellitus, serious cardiovascular disease, cere b ro v a s-
cular disease, thromboembolic disease, and marked obesity
( G o o ren, 1999). The presence of a pro l a c t i n - p roducing pitu-
i t a ry tumor or a strong family history of breast cancer is a
contraindication to beginning estrogen administration.
S e v e re lipid disorders with cardiovascular complications are
contraindicated to beginning testosterone administration
( G o o ren, 1999). Given that immobilization poses serious
risks for deep vein thrombosis and that sex steroids incre a s e
that risk, hormone therapy should be discontinued 3 to 4
weeks prior to any elective surgical pro c e d u res. Tre a t m e n t
may resume once patients are fully mobile again (Goore n ,
1999). It should be noted that suppression of the natal sex
h o rmones combined with cro s s - h o rmone therapy will alter
re p roductive capacity in patients, so sperm storage for
genetic males and cry o p re s e rvation of eggs for genetic
females might be presented as an option to maintain the
possibility of having their own biologic offspring later in
life (Jain & Bradbeer, 2007).
Transgender youth frequently re p o rt
verbal and physical harassment,
assault, and a lack of feeling safe
at school.
58 PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1
Male-to-Female (MTF) Cross-Sex Hormone
Treatment
E s t rogen is prescribed in an increasing dose schedule to
induce female sex characteristics and in addition to the
GnRHa regimen, which has already re n d e red the patient
h y p o g o n a d o t rophic (Delemarre-van de Waal & Cohen-
Kettenis, 2006). Breast development will begin almost
immediately upon estrogen administration, will proceed in
a cyclical fashion, and will be as large as can be expected
after approximately two years of treatment (Gooren, 1999).
G o o ren (1999) re p o rts satisfaction in breast size by patients
in 40% to 50% of cases, noting that size attained may not
be pro p o rtional to the male chest and height dimensions,
resulting in dissatisfaction with size of breasts in the
remaining 50% to 60% of cases. Breast augmentation sur-
g e ry may be desired later in these patients. Female body
shape will also begin to develop with increased subcuta-
neous fat deposits and a loss of lean muscle mass
( D e l e m a rre-van de Waal & Cohen-Kettenis, 2006; Goore n ,
1999), as well as softening of the skin, thinning of body
h a i r, and a less firm erection (Jain & Bradbeer, 2007).
E s t rogen treatment will be re q u i red for the remainder of the
p a t i e n t s life to prevent symptoms of hormone deprivation
and osteoporosis (Delemarre-van de Waal & Cohen-
Kettenis, 2006; Gooren, 1999).
Ethinyl estradiol is an oral preparation, administered in
50 to 100 mcg/day dose, and has been found to be an eff e c-
tive and inexpensive option. If there are concerns about
t h rombosis, oral 17 !-estradiol valerate (2 to 4 mg/day) or
t r a n s d e rmal 17 !-estradiol (100 mcg twice weekly) may be
used with less risk (Gooren et al., 2008). No evidence sup-
p o rts the use of progestagens to enhance the feminization
p rocess, and they have been found to cause venous varico-
sis and increase salt/water retention, thus raising blood
p re s s u re. Additionally, one-large scale study of the use of
e s t rogens combined with progestagens in postmenopausal
women revealed an increased incidence in breast cancer as
well as cardiovascular disease in association with this hor-
mone treatment (Gooren et al., 2008).
Female-to-Male (FTM) Cross-Sex Hormone
Treatment
Te s t o s t e rone is prescribed in addition to the GnRHa re g i-
men to inhibit menses and induce male sex characteristics, or
virilization of the patients body (Gooren et al., 2008). Specific
changes include body and facial hair growth typical of males,
coarser skin, muscle growth and male body shape, clitoral
e n l a rgement in varying degree, increased libido, thickening of
the vocal cords, and potentially male pattern baldness if it
runs in the patients family (Jain & Bradbeer, 2007). After 6 to
8 weeks of hormone treatment, deepening of the voice occurs
and is irreversible (Gooren, 1999). Te s t o s t e rone may be
a d m i n i s t e red intramuscularly, as well as transdermally via a
gel or transdermal patch. Intramuscular injections of testos-
t e rone esters (200 to 250 mg every 2 weeks) are the most com-
mon method (Gooren et al., 2008). Te s t o s t e rone undecanoate
(a 1000 mg IM depot injection) is administered every 10 to 12
weeks (available in some countries but not every w h e re), and
an androgen gel or transdermal patch have also been found
e ffective at producing steady-state testosterone levels (Goore n
et al, 2008). As with estrogen treatment, testosterone must be
continued throughout life to prevent sex hormone depriva-
tion symptoms and osteoporosis (Gooren, 1999).
Side Effects of Cross-Sex Hormone
Treatment
A re t rospective, descriptive study of 10,152 transsexual
patients (816 MTF and 293 FTM) who received cro s s - s e x
h o rmone treatment from a knowledgeable physician
demonstrated that this is an acceptably safe practice in the
s h o rt and medium term. While there are side effects, as
with any pharmaceutical therapy, mortality was not higher
than a comparison group of age- and gender- a d j u s t e d
Dutch citizens (Gooren, 1999; Gooren et al., 2008). In an
e ff o rt to increase the body of medical knowledge re g a rd i n g
l o n g - t e rmside effects of cross-sex hormone tre a t m e n t ,
G o o ren and colleagues (2008) have established a Web site
for re p o rting side effects that can be provided to both
patients and clinicians (http://www. w p a t h . o rg /
re s o u rc e s _ t r a n s g e n d e r.cfm [click on transgender inform a-
tion: re s o u rce links]).
GnRHa administration will create a hypogonadotro p h i c
state that in girls will suppress menses due to lack of estro-
gen and in boys will block the development of fertility due
to lack of testosterone (Delemarre-van de Waal & Cohen-
Kettenis, 2006). Specific to adolescent patients is the issue
of growth. Pubertal growth spurt will be inhibited by hor-
mone treatment, while the fusion of the growth plates in
long bones will be delayed (Delemarre-van de Waal &
Cohen-Kettenis, 2006). This is not a problem for MTF
patients because women are approximately 12 cm short e r
than males on average, so the pro g ressive closing of the epi-
physes during estrogen treatment results in a shorter than
n o rmal male, but an acceptable height for a woman.
A l t e rn a t i v e l y, administration of growth stimulating dru g s
to FTM patients can assist in achieving an acceptable male
height (Delemarre-van de Waal & Cohen-Kettenis, 2006).
GnRHa treatment may interf e re with accumulation of bone
mass normally seen during puberty due to sex horm o n e
e x p o s u re; however, studies have demonstrated that these
levels increase to normal values during cross-sex horm o n e
t reatment and pre s e rve bone mineral density (Delemarre -
van de Waal & Cohen-Kettenis, 2006; Gooren et al., 2008).
M o re studies are needed to determine if discontinuing
c ross-sex hormones later in life would significantly incre a s e
risks of osteoporosis and bone fractures.
Dutch re s e a rchers (Gooren et al., 2008) re p o rt extensive
study of the effects of cross-sex hormone therapy on card i o-
vascular disease risk factors over the last 15 years. Studies of
MTF transsexuals on estrogen and GnRHa tre a t m e n t
revealed a statistically significant increase in weight, total
body fat, and visceral fat (Gooren et al, 2008). There was
also a statistically significant decrease in insulin sensitivity,
which is believed to be caused by androgen deprivation.
Blood pre s s u re increased slightly, and there was also a slight
i n c rease on arterial stiffness; however, neither was a statis-
tically significant change (Gooren et al., 2008). Studies on
FTM transsexuals on testosterone and GnRHa tre a t m e n t
also resulted in a statistically significant increase in body
weight and body mass index (BMI), as well as an increase in
visceral fat that was not statistically significant. Other sta-
tistically significant changes that negatively affect card i o-
vascular health in FTM transsexuals are increased HDL cho-
l e s t e rol, triglycerides, and decreased insulin sensitivity
( G o o ren et al., 2008). The re s e a rchers contend that these
negative changes may be attributable to increased body
weight and fat. It should be noted, however, that overall
c a rdiovascular mortality and morbidity in both MTF and
Pediatric Ethics, Issues, & Commentary
PEDIATRIC NURSING/January-February 2010/Vol. 36/No. 1 59
FTM transsexuals was not elevated (Gooren et al., 2008).
G o o ren and colleagues (2008) recommend advising trans-
sexual patients to maintain a healthy lifestyle and dietary
behaviors to prevent cardiovascular disease and metabolic
s y n d rome.
R e s e a rch has found that hormone-dependent tumors
a re practically not occurring in hormonally treated FTM
and seem a rare occurrence in MTF transsexuals (Goore n
et al., 2008, p. 23). For those who begin cross hormones as
adolescents, exposure is greatly increased over the course of
a lifetime. There f o re, the lack of prevalence of horm o n e -
related tumors in the transsexual population should not be
c o n s i d e red irrelevant nor warrant reduced surv e i l l a n c e .
G o o ren et al. (2008) have documented several cases of pro-
lactinoma (lactotroph adenoma) following high-dose estro-
gen treatment in MTF patients with normal serum pro-
lactin levels prior to therapy, as well as the formation of a
p i t u i t a rymicro p rolactinoma in a patient on norm a l - d o s e
e s t rogen for 14 years. There f o re, Gooren et al. (2008) re c-
ommend long-term monitoring of serum prolactin levels in
MTF patients on estrogen. Two cases of breast carcinoma in
MTF patients on estrogen treatment have been re p o rted, as
have breast fibroadenomas (Gooren et al., 2008). However,
out of approximately 2,200 MTF patients with over 30 years
of treatment in the Dutch clinic, no case of breast cancer
had been observed until re c e n t l y, when one case was
re p o rted (Gooren et al., 2008). Despite these statistics,
G o o ren and colleagues (2008) maintain that these subjects
have had varying exposure to estrogen (from 1 to 25 years),
which prevents one from drawing firm scientific conclu-
sions about the risk of breast cancer with long-term estro-
gen exposure. In addition, breast cancer has also been
re p o rted in a FTM transsexual post-bilateral mastectomy
while on testosterone treatment. There f o re, MTF transsexu-
al patients should be advised to do breast self exams and
have mammograms as recommended for women, and FTM
patients should have axillary lymph nodes examined as
well (Gooren et al., 2008; Jain & Bradbeer, 2007; Sobralske,
2005).
O rchidectomy (surgical removal of the testes) prior to 40
years of age has been found to prevent the development of
benign prostate hyperplasia and prostate cancer (Gooren et
al., 2008). The ovaries of FTM transsexuals receiving testos-
t e rone treatment look similar to polycystic ovaries, which
a re more likely to develop malignancies (Gooren, 1999;
G o o ren et al., 2008). Oophorectomy (surgical removal of
ovaries) is recommended in Dutch clinics once patients are
eligible for surgical sex reassignment (Gooren et al., 2008).
While not without risks, cross-sex hormone treatment has
been shown to be acceptably safe by Dutch re s e a rchers at
clinics that have been administering these treatments since
the 1970s. Data should continue to be collected on adverse
e ffects that present with long-term use to determine if long-
t e rmtreatment with cross hormones is reasonably safe with
lifetime usage, beginning in adolescence, or if the tre a t-
ment should be discontinued at a certain age (Gooren et al.,
2008).
P a rts II and III of this series will feature medical and
nursing care for sex reassignment surgeries for female to
male transition and then male to female transition.
R e fe r e n c e s
A m e rican Association of Pe d i a t ri c s, Committee on Bioethics. ( 1 9 9 5 ) .
I n fo rmed consent, parental permission, and assent in pediatri c
p ra c t i c e. Pe d i a t ri c s, 95(2), 314-317.
B rill, S., & Milazzo, C. ( 2 0 0 8 ) . S e rving transgender youth in your pra c -
t i c e. Presented at the Nort h e rn Califo rnia Conference on
Transgender Health and We l l n e s s, Rohnert Pa rk, CA: October 10,
2 0 0 8 .
C o h e n - Ke t t e n i s, P. T., Delemarre-van de Waal, H.A., & Gooren, L.J.
( 2 0 0 8 ) . The treatment of adolescent tra n s s ex u a l s : C h a n g i n g
i n s i g h t s. J o u rnal of Sexual Medicine, 5, 1892-1897
C o h e n - Ke t t e n i s, P. T., & van Goozen, S. H . ( 1 9 9 8 ) . P u b e rtal delay as an
aid in diagnosis and treatment of a tra n s s exual adolescent.
European Child & Adolescent Psychiatry, 7, 246-248.
Dean, L., Meyer I.H., Robinson, K., Sell, R.L., Sember, R., ... X av i e r, J.
( 2 0 0 0 ) . Lesbian, gay, bisexual, and transgender health findings
and concern s. J o u rnal of the Gay and Lesbi an Medical
Association, 4( 3 ) 1 0 2 - 1 5 1 .
D e l e m a r r e - van de Waal, H.A., & Cohen-Ke t t e n i s, P. T. ( 2 0 0 6 ) . C l i n i c a l
management of gender identity disorder in adolescents: A proto-
col on psychological and paediatric endocrinology aspects.
European Journal of Endocri n o l o g y, 155(1), 131-137.
Gibson, B. G . ( 2 0 0 8 ) . Presented at the Nort h e rn Califo rnia Confe r e n c e
on Transgender Health and We l l n e s s, Rohnert, CA: October 10,
2 0 0 8 .
Gooren, L.J. ( 1 9 9 9 ) . H o rmonal sex reassignment. I n t e rnational Journ a l
of Tra n s g e n d e rism, 3, Retri eved from http://www. i i av. n l /
e z i n e s / we b / I J T / 9 7 - 0 3 / nu m b e r s / s y m p o s i o n / i j t 9 9 0 3 0 1 . h t m
Gooren, L.J., Giltay, E.J., & Bunck, M.C. ( 2 0 0 8 ) . L o n g - t e rm treatment of
t ra n s s exuals with cross-sex horm o n e s : E x t e n s i ve personal ex p e-
ri e n c e. J o u rnal of Clinical Endocrinology and Metabolism, 93( 1 ) ,
1 9 - 2 5 .
Jain, A., & Bra d b e e r, C. ( 2 0 0 7 ) . Gender identity disorder: Tr e a t m e n t
and post-transition care in tra n s s exual adults. I n t e rn a t i o n a l
J o u rnal of STD and AIDS, 18, 147-150.
J e n n i n g s, K. ( 2 0 0 9 ) . The Gay, Lesbian, Straight Education Netwo rk .
R e t ri eved from www. g l s e n . o r g
M eye r, W., Bockting, W., Cohen-Ke t t e n i s, P., Coleman, E., DiCeglie, D. ,
D evo r, H., et al. ( 2 0 0 6 ) . The standards of care of the Harry
Benjamin Gender Dysphoria Association, 6th ve r s i o n .
I n t e rnational Journal of Tra n s g e n d e rism, 5. R e t ri eved from
h t t p : / / w w w. i i av. n l / e z i n e s / we b / I J T / 9 7 0 3 / nu m b e r s / s y m p o s i o n / i n d ex
- 3 . h t m
M i l a z zo, C. ( 2 0 0 8 ) . S e rving transgender youth in your pra c t i c e.
Presented at the Nort h e rn Califo rnia Conference on Tra n s g e n d e r
Health and We l l n e s s, Rohnert Pa rk, CA: October 10, 2008.
R ay, N. ( 2 0 0 7 ) . Lesbian, gay, bisexual, and transgendered yo u t h : A n
epidemic of homelessness. R e t ri eved from http://www. t h e t a s k
fo r c e. o r g / r e p o rt s _ a n d _ r e s e a r c h / h o m e l e s s _ yo u t h
Roughgarden, J. ( 2 0 0 4 ) . E vo l u t i o n s ra i n b ow. B e rke l ey and Los
A n g e l e s, CA: U n i versity of Califo rnia Press.
Selekman, J. ( 2 0 0 7 ) . H o m o s exuality in children and/or their parents.
Pe d i a t ric Nursing, 33(5), 453-457.
Shield, S. ( 2 0 0 7 ) . The doctor wont see you now : Rights of tra n s g e n d e r
adolescents to sex reassignment treatment. N ew Yo rk Unive r s i t y
R ev i ew of Law & Social Change, 31(2), 361-433.
Skidmore-Roth, L. ( 2 0 0 7 ) . M o s by s nursing drug refe r e n c e. S t . L o u i s,
M O : M o s by Elsev i e r.
S o b ra l s ke, M. ( 2 0 0 5 ) . P ri m a ry care needs of patients who have under-
gone gender reassignment. J o u rnal of the American Academy of
Nurse Pra c t i t i o n e r s, 17(4), 133-138.
Wa l t e r s, B. (2007, May 4). 2 0 / 2 0 : Secret self. Pa rts 1-5. R e t ri eve d
Ja nu a ry 14, 2010, from http://www. yo u t u b e. c o m / wa t c h ? v =
U t p a m 0 I G Ya c
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