Hi, I’m Wendy Zukerman and this is Science Vs from Gimlet Media. On today’s show: Being Transgender: What makes us the gender we are? And what should you do if your kid doesn’t fit the mold?

<<something that’s getting a lot of attention recently, the subject of being transgender…>>

Recently, transgender people …  have been in the spotlight a lot. [1] There’s all these trans characters on TV shows like.. Transparent…and Orange is the New Black

<<I’m finally who I’m supposed to be… do you understand? I can’t go back>>

Caitlyn Jenner came out as trans a few years ago[2] … to a flurry of publicity

How do you feel? Fabulous

Meanwhile … more kids are exploring their gender[3] and coming out as trans[4],[5],[6],[7],[8]  One study found that the number of kids seeking medical care for gender issues quadrupled in the last few years[9],. 

For some, this an exciting time, with more support of transgender folks. But others are nervous about it. They’re saying wait a minute…  what’s happening here?[10] Why does it seem like there are there more trans people all of a sudden? And could all this focus on trans folks be endangering kids ?

We’re doing barbaric things by cutting body parts off and jamming kids with hormone therapy. We’re ruining people’s lives.

This all came to a head a few months ago when it was reported that the Trump administration is considering a new legal definition of gender for the federal government  — it’s one that basically says there’s no such thing as being transgender. And the genitals you’re born with pretty much define whether you’re a man or a woman …[11] [12]

So what’s going on here?! Who’s got the evidence to back up their claims?  To find out we’re going to dive into the following questions

  1. What makes us the gender that we are?
  2. If a kid says they are transgender, what should you do?
  3. If you change your body with hormones and surgery … what are the risks?  

When it comes to gender, there’s lots of opinions.. But then, there’s Science.

AHHHHH

Actually… “science” has messed up its treatment of transgender people for decades… we’ll talk about that too...

Science Vs coming up just after the break..

BREAK 

Welcome back… today we’re talking about the science of being transgender…. And we wanted to start this question of what makes us the gender that we are?  Like.. why do I think I’m a woman? …

And to find out we headed to Mount Sinai Hospital in Manhattan.. To meet Joshua Safer, who directs the Transgender Medicine Center[13].

Wendy: This is an amazing array that you have on your desk

Joshua: of stuff. Yeah. Well you know how organized people are with a big mass like it's everything is exactly where it needs to be.

Wendy: It's like it's like a beautiful mind. What I’m looking at...

And right after I gave Josh a hard time for his clutter, he started schooling me...because I thought not that many people were transgender.

WZ: I mean cause it is rare-

JS It’s not rare. No That’s false. We’re talking about by surveys 0.5 percent of the population - that’s one in 200… 1 in 200 is a lot that’s not rare.

It’s estimated that more than a million Americans are trans[14] [15]. Which means their gender identity -  that is, how they feel, doesn’t match the genitals they were born with. Like maybe you identify as a woman, but you have a penis.  And that idea can be a bit hard to wrap your head around… because we often think about our genitals and our gender going hand in hand, you know just like that expert on anatomy told us in the 90s.  

Boys have a penis and girls have a vagina

Ok… so that’s from Kindergarten Cop… it is essentially what Trump is saying too though… So is it science? …

WZ: if you have a penis. Are you a man?

JS So your genitals never defined your sex and that that narrow narrow definition has not existed

WZ: for decades?

JS: Correct.  I mean that's that's just that's just so wrong.  

And one of the reasons Josh says it’s so wrong is because there are people who are born without a clear penis or vagina - and yet many say they feel like either boys …. Or girls. That is, they have a sense of their own gender, even if what’s between their legs isn’t obviously a penis or a vagina. There’s also people born with no genitalia at all[16] [17] and these people identify as something. So from this scientists know - and have known for a very long time - that feeling like woman - doesn’t live in your vagina.

It did get me thinking though… could gender be about chromosomes? Like if babies are born with an X and a Y -- then will they be males? Well Josh says, not necessarily. We’ve got lots of evidence from other conditions - where people have an X and Y chromosomes but they’re women[18]. Like Josh told us about this one particular condition.

JS you will be born with a very visible and conventional looking vagina

WZ: So even though these individuals are X Y do most of them identify as females?

JS That's exactly the point. Almost all of them have female gender identity. 

Now most people who are trans don’t have these conditions[19]… but the fact that these conditions exist tells scientist that your sense of your own gender doesn’t simply live in an X or Y chromosome… or even in your genitals. Which raises the obvious question… of where does it live?

And it turns out that trying to answer this question has led scientists down a path that caused big problems for transgender people for decades. And it all started with this idea that

Whether we feel like a boy or girl … or something in between… was largely shaped by our environment. That is, that nurture was more important than nature.

JS We were certain that was in quotes a known thing for decades.  

WZ The reason I think I’m a woman is because my parents raised me as a woman.

JS Yeah exactly right.

WZ And so if they had raised me as a man as a boy and started calling me Bobby I would have been perfectly happy with?

JS Yes. So. So yeah. Exactly that.

The idea started to take off in the 60s [20] [21]  and in the 80s… when Josh was in medical school that’s what he was taught…  And for doctors like Josh, this wasn’t just theoretical. They were acting on it.  Josh remembers seeing baby boys whose penises hadn’t formed properly… and more senior doctors would talk to the parents about what to do.

JS You would say your child is healthy but this is, we have this slight abnormality, but don't worry because we can fix it surgically.

The fix ?… was simply turning a penis into a vagina. And afterward, they’d tell the parents … Don’t worry, gender is all about how you raise your kid.  And you have a girl now … here’s what you do

JS Well you want a very feminine name you want to make you want to put them in dresses you want to hand them a Barbie doll you want to do whatever you can get away with

WZ And this was done?

JS That was standard operating procedure…

And Josh says that this standard operating procedure fed into the way that doctors treated trans people too[22],[23],[24]....The fact that trans people said: I was raised as a man but I feel like a woman - didn’t make sense in a world where gender was basically shaped by your environment. And so to the medical community, the only possible explanation for trans people saying this was that they were sick. [25],[26] Now, not all doctors thought this way[27] — but enough did that in 1980, the DSM - the psychiatrist’s bible - first started labelling trans people as having a mental disorder.[28],[29]  In fact, they put it in under the same heading as pedophilia and bestiality[30]. And so trans people would be sent to therapists to be cured… Producer Meryl Horn asked Josh about this.

MH: And so what happened when they went into that counseling? The goal of it was, basically, get yourself out of it?  

JS: Yeah. You convince yourself that. Actually that's just not true what you think. And this is your body and this is what you are. And the fact that you think you are otherwise is wrong.  

In some cases trans people were forced into hospitals for months on end [31] or subjected to electric shock therapy[32]. [33]And so the medical establishment went on like this for years…  but things started to shift in the 1990s and into the 2000s[34] [35]… there was this burst of activism from the trans community[36],[37]

<<they are not going to be fired for who and what they are, they are not...>>

and protests across the country where trans people were saying - I know who I am! I’m not crazy, listen to me!!…

We’re going to fight to the end… we’re going to fight… [38]

And then something happened that ripped the dogma to shreds…  reports started coming out about some of these kids who were given vaginas by their doctors … And it turned out the Barbie dolls weren’t working.  A bunch of these kids who were raised as girls -- were saying I’m a boy.[39]. One mum who went through this with her little kid went on “Oprah” in 2000[40] .

<<I had complete faith in the doctor. I believed it would be best. There were doubts along the way, but I couldn’t afford to contemplate them, because I couldn’t afford to be wrong, I couldn’t have faced the alternative.

That you made this horrible mistake?

Yes.>>

Just four years later, in 2004, her son killed himself.[41] … It was becoming clear that gender didn’t just come from the environment…There was something inside these kids telling them the gender that they were…  and for Josh, reading about these kids completely upended what he knew. And now, he says ...

JS We cannot change people's gender identity despite the most intense program for doing so. Right, I mean what is more intense than raising some but you know it's like the Truman Show. Right. We're raising somebody from infancy to believe something, having their parents part of the plan and surgically altering their body for the plan... And still it fails. If that's not going to work. I don't think anything is going to work to change your gender identity. So I'm calling that a failure.  

WZ: And where do you think like doctors at the time got that confidence to just say, well, to you know let's just make a vagina and make sure we call her Sally?

JS:  It felt logical. I can't claim that there was that there was

WZ: FELT — oof 

JS Yeah, the medical community has been wrong.

The medical community was wrong about those babies … and it was wrong about people who are transgender. In 2006 the full extent of how bad things were for trans people reached the scientific community. A large survey - the first of its kind - came out and it showed that huge numbers of trans folks were attempting suicide.[42] 

JS: It is horrible. It’s terrible. You know people suffer in massive ways when when we make mistakes 

And that takes us to where we are now. Through this messed up history -- we know that there is something hardwired that helps us feel like a boy or a girl.. Or somewhere else on the gender rainbow[43]. … so our next question is this: what is that thing?

WZ: So why is  it that I think I'm a woman.

JS:  Why is that the reason you think you're a woman is at least heavily because there is something in your brain that is programmed to tell you that you are a woman

WZ: What is that thing in my brain?

JS: Well that we don't have worked out.

Scientists have looked in the brain but.. so far they haven’t found a particular thing that always shows up in, say, people who identify as women.[44] .… As of now, it’s looking like I know I’m a woman partly because of a complicated dance between my hormones and genes. Genes really seems like a big piece of this puzzle. In fact… one study published a few years ago looked at identical twins and found that when one twin was transgender … 40 percent of the time, the other twin was too[45]. And in the land of genetics, that’s a lot. There are even case reports of twins raised apart and both coming out as trans.[46] So even though we don’t know exactly what makes up our gender… we know that sometimes what’s under our skirts and how we feel about ourselves -- doesn’t match up.

JS: There is no question within those medical communities nobody raises their hand and says Oh do we believe that transgender people are legit. That just isn't a thing anymore and a conventional medical community. So the idea that that out there in the lay world that people think that there are doctors debating. That's not true.[47] 

Still though, it took a long time for science to work this out. [48] [49] The book that psychiatrists use to treat their patients -- the DSM-  it only stopped listing transgender as a mental disorder five years ago.  The World Health Organization only made the switch… this year. [50],[51] [52] 

After the break -- the newest controversy. If your child tells you they’re in the wrong body…mummy… I’m a boy, not a girl.

kids who are saying things like God made a mistake or I want to cut off my penis.

What should you do? That’s coming up after the break.

BREAK

Welcome back. Before the break, we were talking about what makes us the gender we are.

And even though we don’t know exactly what that things is…  it’s clear that for some people their gender identity doesn’t match the body they were born with. Amongst most scientists, that is not controversial. What feels controversial now though, is how you handle kids who say they’re transgender. What do you do if your two year old son says I’m not a boy, I’m a girl? And this is what a lot of people have their knickers in a twist over ...because some say that you need to trust your kid and do something about it -- while others think … no no no... this is just a phase and by indulging it you’ll ruin your kid’s life.

They’re going to make moves where the kid can’t go back… Can’t go back. Life is over… you’ve literally turned their life down a dark path…

Children are having their normal psychological development interruptedthis is child abuse… 

And at the heart of this debate is this one question… Can a child really know if they’re transgender or not?[53] Because if they can’t … and a lot of these kids will just grow out of it… then it is kind of scary to think these kids might be put on life changing drugs. So, maybe our knickers should be in a twist?

We talked about this with Laura Edwards Leeper [Leep-er]...  a kid’s clinical psychologist and associate professor at Pacific University in Oregon. She was also one of the first clinicians in the US to treat transgender kids.[54] 

LEL: I was really the only psychologist in the US who was starting to do assessments for transgender adolescents who were seeking medical interventions.So that part was pretty anxiety producing 

Laura has been working with trans kids for over a decade -- in her career she reckons she’s worked with around 500 of them. So we took this question to her ... about whether this really is just a phase for trans kids … Because there’s a lot of numbers getting thrown around … that make it sound like A LOT… will just grow out of this[55].

80-95% of children would naturally grow out of it. >>

In 98% of the cases in boys…

As many as 95% will come to embrace their bodies and identify with their biological sex.

And so we asked her… is it true? Do the majority of kids grow out of it?

Well the research doesn't doesn't show that. I'd say that's incorrect.

 

Laura told us that some studies seem to show that lots of trans kids change their mind. And here’s what those studies are doing: They take a group of kids from a gender clinic and follow them ... and they find that most aren’t trans when they grow up. [56] [57] [58] [59] But Laura says we have to be careful with what this means…  because a lot of these studies are just scooping up all the kids at the clinic[60] [61] [62] …not just those who say they’re trans. And kids end up at gender clinics for all sorts of reasons …  

LEL: They can be a boy and wear dresses and like sparkly things, and that doesn't mean they're a girl,

WZ: Or they've just worked out that dresses are really fun and many men are missing out? Exactly

LEL: I think what sometimes has happened in the earlier research as they've lumped all of these gender diverse kids into the same category.

Basically Laura says these studies are tracking all kinds of kids - gay kids… tom boys… boys who like nail polish - and then saying: hey! Most of them aren’t trans. True, but not particularly useful. Laura says you really need to focus on the  kids who are having issues with their gender identity.. So for example… the kids who strongly agree with statements like … “I wish I had been born a boy” or “Every time someone treats me like a girl I feel hurt.” [63],[64]  and Laura says has met a LOT of kids like this.

Sometimes we have these little kids who are so like just disconnected from their body, and they just really feel so strongly that this is not the body I'm so supposed to have-01

The only study we’ve found that zoomed in on kids like this… found that out of 45 of them… 44 grew up to be transgender.[65],[66],[67]. So only one kid didn’t. Now this is just one study, but it lines up with Laura’s experience too.

WZ: In your practice have you seen any kids that are super insistent and then do ultimately stick with the gender they were born with? switch?

LEL Yes, I have, Yeah I have not many, not many of them. But if we're talking about the kids who are saying things like, “God made a mistake” or “mommy why did you make me this way” You know or “I want to cut off my penis.”

WZ: Oh my God. And you hear kids saying that stuff.

LEL Absolutely.  I mean those are the kids that tend to be more likely to continue.

From the best evidence we could find, the majority of kids who insist that they’re trans… won’t grow out of it. But Laura says this whole argument over exactly how many kids will change their mind is kind of missing the point. Because ultimately, no one can predict which way any kid will go… so you have to treat each little tacker as they come.

LEL: And so we can't know for one from one child to the next what their ultimate identity is going to be. So you know I really think that this debate we kind of need to just put that to rest a little bit because I don't think it's really helping the cause on either side; it’s just confusing things.

But even if kids are just exploring their gender … parents are still wondering, can they do any damage if they help their kids transition. ‘Cause a lot of the talking heads on TV are yelling about giving kids hormones and yukky chemicals and surgery … so is any of that justified? Well, Laura says calm down. No one should be putting young trans kids on hormones.

LEL: Never. I mean, I'm not even sure, honestly, where they're getting that information. It’s just not true. I don't know of a single place in the entire world that would consider giving hormones to young children. I mean, that's crazy.

The first step for a kid, if they want to, is to let them wear whatever clothes fit their gender… let them pick a name that feels right for them … and use the pronouns — he, she, they — whatever your kid wants. This is called socially transitioning. And Laura says it can be huge for a kid.

LEL: There is often a light switch that kind of changes everything and causes the child to just you know feel much better about themselves.

And everyone we spoke to told us that not letting your kid do this — isn’t a benign choice. Generally, trans kids have really high rates of depression and suicidal thoughts.[68],[69],[70] Yet, studies focused on just socially transitioned kids … find their mental health was almost as good as non trans kids [71] [72] [73] [74],...   Plus…  wearing a dress or cutting your hair… not exactly medically risky…

OK, so that idea that young kids are being put on chemicals: it’s bunk. In fact, the first time a trans kid will be put on medication to help them transition ... will be when puberty kicks in, and they’re around 12 years old.[75]  And even now they’re not taking hormones  they’re taking something called puberty blockers. [76],[77],[78].

These meds suppress a hormone that triggers puberty.[79],[80]  And this gives the kid more time to sort through their gender identity before their body really starts to change…While it sounds hectic to stop puberty in its tracks… actually Laura told me this is tried and tested.  These puberty blockers have been used for over 30 years.[81] [82],

LEL: It's been used for years for kids with precocious puberty. So you know younger kids who start puberty at too at a young age, like 6 or 7 or whatever

WZ: What a name isn't it? Precocious puberty…

LEL: Yeah  So it's been used for a long time for that-01

Precocious puberty! It sounds like the Hermione Granger of puberty…and because puberty blockers have been used since the ’80s, we can see how the kids who used them turned out as adults. And..? As best as science can tell — these kids are healthy when they grow up.[83] [84] [85] [86] [87] [88]  . [89] . [90] [91] [92] [93]

LEL So it's really an incredibly safe intervention.

WZ: And is it reversible?

LEL: The blockers are extremely reversible, and as far as we know there are no negative side effects[94],[95]..

So far so good. No life-changing decisions. No dangerous meds. The kid can get off the trans- train any time. But there is a time trans kids do have to make a life-changing decision… And that’s when they are old enough to go on hormones… it usually happens when they’re around 16.[96],[97],[98],[99],[100] 

And this is a big decision: This means… you’re effectively using hormones — oestrogen or testosterone — [101] to change your entire body and your brain[102] So what are the risks now?

To walk us through it we’re talking to Colt Keo-Meier [Colt Gow- Meyer]. He’s a clinical psychologist in Texas[103]. And Colt remembers what it was like to be one of those insistent kids who knew who they were at a young age ...

CKM: I actually have video at age 3 sitting on my mom's lap And we were watching Alvin and the Chipmunks and my dad was saying oh you know you're sitting on your mom's lap. You love Alvin and the Chipmunks. When you become a mother maybe you're going to watch Alvin and the Chipmunks with your children. And I looked at him I said NO! I said I'm not gonna be a mother. He said well OK you don't have to be a mother. I'm going to be a father. He was like you know what. OK. If you work hard you can be anything you want to be.

Colt transitioned more than a decade ago ... And now he helps others transition as well…  Colt told us that taking hormones can have dramatic effects all through your body… He says it’s kind of like going through puberty again.   Your skin, fat, muscles, voice and even libido can change[104].[105].. Colt told us about what it’s like taking testosterone.

CKM: So you get more of a gut, less hips and then you'll also get increased muscle mass and you'll find that when you work out it actually like has real quick impact that you can see which a lot of  my friends would just kind of give me the eye and be like how come now you can exercise and get all of these effects from me and I was like testosterone like I want that and I was like Do you want a beard and a low voice like no.

Producer Odelia Rubin spoke to a bunch of people about their transition… and what it was like taking hormones. And everyone’s experience was a bit different.

Truly there’s all these weird puberty things

OR: Like what?

Like hair in weird places, the ever-enjoyable voice cracking.

You know I’m able to participate in No Shave November right now, so that says something

Libido that definitely goes through the roof when you first start hormones.

I grew boobs and was going down stairs and --things were bouncing in different ways than I was used to… My experience of being sexual was yes yes yes no no… no no… finally!!

Yeah, so taking a bunch of hormones can have a huge effect on how you feel, and it causes these major changes in your body. From the studies we have, though, the hormones  actually seem pretty safe. They might increase your risk of cardiovascular disease, like blood clots.  [106][107] But the big unknown here, is how they affect your fertility. Here’s Colt again.

CKM: And so historically when folks started hormone therapy and this was my experience as well just 11 years ago we were told that you know there's not enough research and just pretty much assume that once you start hormone therapy that you're rendering yourself infertile. So just make sure that you want to do that. And that's pretty terrifying y’know.

But now we’re actually seeing that there are trans men who despite taking a bunch of testosterone have still gotten pregnant.[108] [109]

CKM: We're seeing a lot of live healthy births. People seem  to be really happy I'm connected on Facebook to hundreds of parents who happen to be trans who have so many cute kids.

So while we know that some transmen are getting knocked up, there is a big catch here. As far as we know, the only way a transman can get pregnant... is if he transitioned after his body went through puberty. For both transwomen and transmen, they need to go through puberty to be fertile.[110] [111] [112][113] [114] This means that for those kids who are going on puberty blockers and then going straight onto[115] hormones… they may be infertile.  With all these unknowns[116][117] … and risk to your fertility…  you’ve got to wonder. Do people regret this? Colt asks his patients this all the time.

CKM: And the most common answer is no. And the second most common answer is yes I wish that I would have known about this and started this way earlier in my life.

Studies of adults who have transitioned… using hormones AND surgery…It finds that the vast majority don’t regret it[118] [119] [120] [121],[122], [123], [124], [125]. One of the largest studies of its kind - which surveyed thousands of transgender people - found that less than 1 percent regretted their testicles or ovaries removed[126] Less than one percent.

So when it comes to being Transgender … what do we know?

  1. What makes us the gender that we are? While science doesn’t know for sure… we do know a lot of this is in our genes. And the best evidence we have tells us that this is not a choice. You are the gender you are. And sometimes it doesn’t match your genitals.
  2. If a kid says they are transgender, what should you do? Let your kid explore who they are, if they want, cut their hair, or let it grow out - that’s fine. And if they’re about to hit puberty - talk to your doc about puberty blockers.
  3. If you decide to change your body with hormones and surgery… will you regret it? The best evidence we have is that very few people regret getting surgery or taking hormones…. But there is one big risk - fertility. Particularly for kids who go straight from puberty blockers to hormones…

While there might be some risks with changing your body with hormones or scalpels… something much scarier is looming over the transgender folks[127][128] … and that’s suicide. A survey of more than 30,000 trans people found that  40% attempted suicide in their lifetime.[129] That’s way higher than the general population - it’s 9 times higher. [130]  Here’s Colt Keo-Meier ...

CKM: the transgender population has the highest rate of suicide attempts in the demographic in the United States[131][132]

And what we’re learning now is that being transgender - in itself - doesn’t seem to be bad for your mental [133]health. Turns out… what is bad for your mental health.. Is the way trans-people are often treated. They get bullied, kicked out of their homes and attacked[134].The science is telling us that it’s this mistreatment that’s the biggest problem for transgender people[135] [136] . It’s not hormones or surgery. Not surprisingly, when people don’t get treated like garbage, it makes a big difference.

CKM: And I think the best thing about transition was having my family and friends support me all the way through it and having my priest from the small town Texas write me a letter about how brave I was and say I was always welcome in church. Yes hormones are important and awesome. But in terms of like why I am doing so well and so happy is because of all the sources of support that I've got.

That’s Science Vs.

CREDITS

Hi Odelia and Meryl!

More than 130 citations!

This episode was produced by Odelia Rubin and Meryl Horn along with me Wendy Zukerman and Rose Rimler. Our senior producer is Kaitlyn Sawrey. We’re edited by Blythe Terrell. Editorial assistance by Rebecca Kling. You can check out her show which is called Trans-Specific Partnership Podcast. We’ll link to it in the show notes.

Fact checking by Michelle Harris, Meryl Horn and Rose Rimler. Mix and sound design by Emma Munger. Music by Emma Munger and Bobby Lord.  

Thanks to all the researchers we got in touch with for this episode - including Dr. Jack Turban, Professor Anne Fausto- Sterling, assistant professor Samantha Busa, Associate Professor Susan Stryker, Dr. Katrina Karkazis [car-KAY-zus], Professor Neill Epperson, Paula Neira, Professor Michelle Forcier, and Professor Joan Roughgarden. And thanks to all the trans folks who shared their stories with us

Thank you! Also thanks to the Zukerman Family and Joseph Lavelle Wilson.  

Next week… the final episode of the season! And we’re following a cold case… a  man is found dead with a stolen identity.. The police don’t know what to do … can science save the day?

I’m Wendy Zukerman… Fact you next week!


[1] https://www.nytimes.com/2017/11/07/us/danica-roem-virginia-transgender.html

[2] https://www.vanityfair.com/style/2016/06/caitlyn-jenner-first-year-vanity-fair-cover-reveal On June 1, 2015, the world met Caitlyn Jenner.

[3] 14% of millennials have felt that their gender identity differs from what is typically associated with the sex they were assigned at birth – this is double the number of those 35-54 who have ever felt this way (7%).

[4] http://www.aappublications.org/news/2018/05/05/pastransgender050518 this says "113 to 464 between 2010-’14." so quadrupled between 2010-2014 - this is for youths who “are seeking medical care for gender dysphoria (GD).”

[5] http://sci-hub.tw/10.1016/j.jsxm.2018.01.016 stats for everyone coming to their clinic (not just kids) : The number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015.

[6] https://www.tandfonline.com/doi/abs/10.1080/0092623X.2012.675022

[7] https://www.sciencedirect.com/science/article/pii/S1054139X1500676X

A dramatic increase in referrals for GD since 2002 was confirmed.

[8] https://e-apem.org/journal/view.php?doi=10.6065/apem.2016.21.4.185

In many countries throughout the world, increasing numbers of gender nonconforming/transgender youth are seeking medical services to enable the development of physical characteristics consistent with their experienced gender. 

[9] http://www.aappublications.org/news/2018/05/05/pastransgender050518 this says "113 to 464 between 2010-’14." so quadrupled between 2010-2014 - this is for youths who “are seeking medical care for gender dysphoria (GD),””

[10] See page 51: “Definitely is - 22% Probably is - 17% Think Transgender is a choice

[11] https://www.nytimes.com/2018/10/21/us/politics/transgender-trump-administration-sex-definition.html

[12] The department argued in its memo that key government agencies needed to adopt an explicit and uniform definition of gender as determined “on a biological basis that is clear, grounded in science, objective and administrable.”

[13] https://www.mountsinai.org/about/newsroom/2018/mount-sinai-elects-dr-joshua-safer-as-first-ever-executive-director-of-transgender-medicine-center 

[14] https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf 0.6 or 1.4 million identify as transgender in the US

[15] https://academic.oup.com/jcem/article/99/12/4379/2833862 Of those surveyed, 131 (0.5%) self-identified as transgender (14).

[16] https://sci-hub.tw/10.1016/j.jpag.2008.11.006 Mayer-Rokitansky-Ku¨ster-Hauser (MRKH) syndrome

is a congenital condition in which a genetic female is born with vaginal agenesis and a rudimentary to absent uterus… All participants had established female gender identity concordant with their gender assignment.

[17] https://sci-hub.tw/10.1007/s10508-005-4342-9 includes cases of “Penile Agenesis” - though these patients still have testicles. They either had gender dysphoria or not, but didn’t mention anybody being without a gender

[18] For example, in 5α-reductase-2 deficiency among 46 XY individuals raised female, a gender role change from female to male (typically after puberty) was reported in 56–63% of the patients (26). Gender role changes from female to male were also reported in 39–64% of 46,XY individuals raised female with 17β-hydroxysteroid dehydrogenase-3 deficiency

[19] While the majority of transgender individuals do not have a disorder of sex development (DSD), studies of persons with DSDs have helped inform our understanding of gender identity"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807860/

[20] https://www.newspapers.com/image/377217994/?terms=%22john%2Bmoney%22%2Bgender from 1969. The sex of a baby is not always apparent at birth.. Decisions then must be made as to medical and surgical procedures which will determine the baby’s sex… “Hermaphrodites are made into females...

[21] https://www.newspapers.com/image/375951458/?terms=%22john%2Bmoney%22%2Bgender “Dr. John Money to speak on “Sex, Gender, and Environment.” from 1963.

[22] Studies of intersex children, in general, substantiate the primacy of psychological factors in gender formation, regardless of the permutations of known biologic variables (hloney, 1970; Stoller, 1972b, 1979). Solidification of gender identity within the first several years of life in intersex patients is strongly correlated with concordance between genitals and assignment (Money, Hampson, and Hampson, 1955a, 1955b, 1956,1957; Hampson and Hampson, 1961)

[23] https://search.proquest.com/openview/356c27382b381365b80ea2c797bc5db0/1?pq-origsite=gscholar&cbl=1818298 

[24] http://b-ok.cc/book/2297506/c9ff5f page 8: Parents ought to be more aware of the need to positively reinforce all infants for those gender characteristics which are consistent with their biological identity….  The effectiveness of treatment in this condition has not been thoroughly evaluated, but guidelines have been developed (Green, 1976)...page 93: “Some basic principles of intervention have been developed over the years in my work with John Money, Robert Stoller, and Lawrence Newman.  They include exploring the child's understanding of the nature of the anatomic distinction between the sexes, educating the child to the impossibility of magically changing sex, and emphasizing the positive aspects of the sex to which the child belongs.”

[25] https://sci-hub.tw/10.1001/archpsyc.1981.01780330082009 Moreover, psychological integration of gender role and identity can¬ not be achieved through surgery. The GD patient's pro¬ found disturbances in object relations, heightened separa¬ tion conflicts, and defects in symbol formation cannot be resolved through surgery.

[26] https://sci-hub.tw/https://doi.org/10.1093/jpepsy/5.1.93 Feeling estranged and isolated from society and their families , these adolescents have impulsive characters , eccentric behaviors , and pervasive anxiety—all of which suggest severe psychopathology .

[27] E.g. Harry Benjamin http://www.mut23.de/texte/Harry%20Benjamin%20-%20The%20Transsexual%20Phenomenon.pdf 

[28] In DSM II, only Transvestitism was listed https://www.madinamerica.com/wp-content/uploads/2015/08/DSM-II.pdf . In DSM III, published in 1980, there’s a chapter on Gender identity disorders http://displus.sk/DSM/subory/dsm3.pdf

[29] the disparity between anatomical sex and gender identity was referred to as the psychopathological condition of gender identity disorder, and this was used for its diagnostic name when it was introduced into DSM-III in 1980.

[30] DSM 1980 http://displus.sk/DSM/subory/dsm3.pdf

[31] Hospitalization can also help to control the adolescents' acting-out while bringing out his/her depression and gender identity confusions (thereby quieting the wishes for SRS) . Spensley an d Barter (1971 ) have reported the apparently successful treatment of an adolescent female transsexual during a 20-month hospitalization .

[32]  Electric shock surgery to transsexuals: https://sci-hub.tw/https://doi.org/10.1192/S0007125000192864. It didn’t work. “All seven transsexual patients had cross-dressed before treatment, and everyone continued to do so in the period up to the final follow-up”

[33] During this time, many psychiatrists and psychologists attempted various “cures” (i.e., attempts to change homosexuals into heterosexuals), including psychotherapy, hormone treatments, aversive conditioning with nausea-inducing drugs, lobotomy, electroshock, and castration (e.g., American Psychological Association, 2009b; Feldman, 1966; Katz, 1976; Max, 1935; Thompson, 1949). These methods proved to be largely unsuccessful (American Psychological Association, 2009b; Friedman and Downey, 1998; Haldeman, 1994).

[34] Broad public attention to the plight of intersexed people arose in 1997 when the “John/Joan” story broke into the general media (“Anatomy Is Destiny,” 1997; Angier, 1997). “John/Joan” soon made his identity public as David Reimer and collaborated with journalist John Colapinto (2000) on a book-length exposé of the case..  The tragic outcome of David Reimer’s story was his suicide in May 2004 after his divorce and his twin brother’s death in 2002. The Reimer case prompted a number of television documentaries on the subject of intersexes and coincided with the rise of an intersex patient advocacy movement.

[35] Determinants of gender dysphoria remain controversial and hypothetical. Although some cases may offer support for Stoller's psychoanalytic etiological theory of "transsexualism" (Stoller, 1975), applicants for sex reassignment present with diverse backgrounds in terms of family dynamics and psychosexual development. While other theorists have posited a biological, deterministic view (e.g., Pillard & Weinrich, 1987), there is insufficient evidence for a biological determinant of gender dysphoria (Gooren, 1984, 1986a,b, 1987, 1991; Coleman, Gooren & Ross, 1989).

[36] https://sci-hub.tw/10.1080/09663690601122309  Jacobs & Cromwell (1992) review a range of anthropological evidence on gender variant individuals to critique the strongly hetero-normative expectation that gender expression and biological sex will be congruent.

[37] P 151 and p 169 “The tremendous burst of new transgender activism that began around 1990… (Transgender History)

[38] http://www.shanahanlaw.com/SophiaLaMarAmandaL-Pore_vs_Twilo.pdf

[39] https://sci-hub.tw/10.1056/NEJMoa022236 Eight subjects assigned to female sex in infancy declared
themselves male, four spontaneously and four others after learning that they were born male.
None have veered from these declarations
.

[40] https://www.healthyplace.com/gender/inside-intersexuality/the-true-story-of-john-joan

[41] https://www.nytimes.com/2004/05/12/us/david-reimer-38-subject-of-the-john-joan-case.html

[42] http://sci-hub.tw//10.1300/J082v51n03_04 Although previous research has assessed the independent

risk factors for attempted suicide among LGB populations, ours is the first study to do so with MTF and FTM transgender persons.

[43] Compelling studies have demonstrated that “gender identity”—a person's inner sense of self as male, female, or occasionally a category other than male or female—is not simply a psychosocial construct, but likely reflects a complex interplay of biological, environmental, and cultural factors

[44] http://sci-hub.tw/10.1007/s10508-016-0768-5

[45] http://sci-hub.tw/10.1111/j.1743-6109.2011.02567.x

[46] https://sci-hub.tw/https://doi.org/10.1080/15532739.2013.750222 

[47] Almost two dozen medical organizations have issued statements supporting trans-affirming health care: https://transcendlegal.org/medical-organization-statements So have a number of psychiatric and social worker organizations: https://www.lambdalegal.org/sites/default/files/publications/downloads/resource_trans-professional-statements_09-18-2018.pdf 

[48] https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF However, one-third (33%) reported having at least one negative experience with a doctor or other health care provider related to being transgender,  

[49] DSM IV - https://justines2010blog.files.wordpress.com/2011/03/dsm-iv.pdf Gender Identity Disorder is listed in chapter on “Sexual and Gender Identity Disorders” and is marked by high “extent and pervasiveness of the cross-gender wishes”

[50] https://www.icd10data.com/ICD10CM/Codes/F01-F99/F60-F69/F64- 

[51] https://www.who.int/health-topics/international-classification-of-diseases Gender incongruence, meanwhile, has also been moved out of mental disorders in the ICD, into sexual health conditions. The rationale being that while evidence is now clear that it is not a mental disorder… there remains significant health care needs that can best be met if the condition is coded under the ICD.

[52] From the DSM 5 pg 450 : “The current term is more descriptive than the previous DSM-IV term gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.”

https://www.scientificamerican.com/article/where-transgender-is-no-longer-a-diagnosis/

[53] https://www.acpeds.org/the-college-speaks/position-statements/gender-dysphoria-in-children 

[54] http://archive.boston.com/bostonglobe/ideas/articles/2008/03/30/qa_with_norman_spack/?page=full 

Last year [2007], the pediatric endocrinologist started a new clinic at Children's Hospital Boston; it is one of a few in the world to give children treatments that change their bodies. Working on a model borrowed from Dutch researchers. And LEL worked in this clinic - https://www.seattletimes.com/seattle-news/health/transgender-kids-a-family-quest-a-medical-quandary/ Laura Edwards-Leeper, a psychologist at Oregon’s Pacific University who studied with Dutch pioneers in the field and helped develop one of the first U.S. programs for transgender kids in Boston in 2007.

[55] https://www.acpeds.org/the-college-speaks/position-statements/gender-dysphoria-in-children

[56] http://sci-hub.tw/10.1080/15532739.2018.1456390 

[57] http://sci-hub.tw/10.1016/j.jsxm.2018.01.016 percentage of children who were referred in childhood and showed persistent gender dysphoria = 40% (which authors note is almost identical to other recent paper- 39%, see below). Seems to be largest study of persistence rates (548 children under 12). Authors note:  the persistence is higher in natal girls (49.1%) compared with natal boys (33.6%).

[58] https://sci-hub.tw/https://doi.org/10.1097/CHI.0b013e31818956b9 Dutch study from 2008 Twenty-one participants (27%; 9 girls and 12 boys) were still gender dysphoric at follow-up (persistence group). Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria.

[59] https://sci-hub.tw/10.3109/09540261.2015.1115754 review discussing differences between earlier and canadian studies showing higher figures and more recent and dutch studies showing lower figures of desistance.

[60] http://sci-hub.tw/10.1016/j.jsxm.2018.01.016 After approval of the local ethics committee, a retrospective medical record review was performed to identify all people seen in our gender identity clinic from 1972 until December 2015.

[61] https://sci-hub.tw/https://doi.org/10.1097/CHI.0b013e31818956b9 We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria

[62] http://sci-hub.tw/http://dx.doi.org/10.1037/0012-1649.44.1.34 “Between 1975 and 2004, 71 girls (age range, 3–12 years) were referred for assessment to the Gender Identity Service, Child, Youth, and Family Program at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada.” mentions that only 60% met the DSM criteria for gender identity disorder in childhood

[63] https://sci-hub.tw/https://doi.org/10.1016/j.jaac.2013.03.016 The Gender Identity Interview for Adolescents and Adults (GIAA),15,16 is a 27-item adolescent and adult informant instrument with 1 factor. The items measure gender identity problems and GD for the past 12 months (e.g., “In the past 12 months, have you felt satisfied being a boy?”). Lower scores on the GIAA reflect more gender atypical responses. The Utrecht Gender Dysphoria Scale (UGDS),17 is a 12-item questionnaire measuring 1 factor. The items measure the intensity of GD (e.g., “I continuously want to be treated like a boy/man.”). There are separate versions of the UGDS for males (UGDS-M) and females (UGDS-F). Higher scores indicate more GD.

[64] http://sci-hub.tw/10.1007/s10508-016-0702-x 

(1) I prefer to behave like a boy. (2) Every time someone treats me like a girl I feel hurt. (3) I love to live as a girl. (4) I continuously want to be treated like a boy. (5) A boy’s life is more attractive for me than a girl’s life. (6) I feel unhappy because I have to behave like a girl. (7) Living as a girl is something positive for me. (8) I enjoy seeing my naked body in the mirror. (9) I like to behave sexually as a girl. (10) I hate menstruating because it makes me feellike a girl. (11) I hate having breasts. (12) I wish I had been born as a boy..

[65]Gender Identity and Body Image. Adolescents’ reports of GD and body image were compared across persisters and desisters (Table 4), and showed that persisters reported more GD than desisters in the mean total scores of both the GIIAA and the UGDS. Clinically, for the GIIAA, scores of less than 3 indicate GD;16 87.2% of the persisters met the criterion compared to 0% of the desisters. For the UGDS, scores of more than 40.0 indicate GD (Steensma, Kreukels, Jurgensen, € Thyen, de Vries and Cohen-Kettenis, unpublished material, 2013); 97.9% of the persisters met the criterion compared to 2.2% of the desisters (1 bisexual, natal girl) (if 1 = 2.2%, then the total was 45- MH) As for body image, the persisters reported more body dissatisfaction for primary and secondary sex characteristics and neutral body characteristics, than the desisters. There were no main effects for sex or significant interactions between sex and persistence for GD or body image.

 https://www.sciencedirect.com/science/article/abs/pii/S0890856713001871

[66] https://www.sciencedirect.com/science/article/abs/pii/S0890856708601422 Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups

[67] https://sci-hub.tw/10.1016/j.jaac.2013.03.016 Intensity of early GD appears to be an important predictor of persistence of GD

[68] https://www.jaacap.org/article/S0002-7138(10)60113-6/pdf Using the Child Behavior Checklist created by Achenbach and Edelbrock in 1983, 84% of feminine boys were reported to display behavioral disturbances usually seen in clinic-referred children. Sixty-four percent of the sample had difficulties with peers that were comparable to those of psychiatric-referred boys. Sixty percent of the sample met the criteria for diagnosis of DSM-I11 separation anxiety disorder. 

[69] http://sci-hub.tw/10.1177/1359104514558431 The most commonly reported associated difficulties were bullying, low mood/depression and self-harming

[70] http://pediatrics.aappublications.org/content/141/5/e20173845  Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3–9 years old) and adolescents (10–17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status)... For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups.

[71] http://pediatrics.aappublications.org/content/137/3/e20153223 (socially transitioning)

[72] https://www.ncbi.nlm.nih.gov/pubmed/28117057

[73] And see: http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.1080/15532739.2017.1414649 for a round up on this^ and other studies, starting pg 7 mentions slightly elevated anxiety, but then “These data show that socially transitioned transgender children are not suffering from elevated levels of mental health issues, as has often been assumed.”

[74] https://sci-hub.tw/10.1080/00926230903375560 When compared to children at other gender identity

clinics in Canada and The Netherlands, parents rated their children’s gender variance as no less extreme, but their children were overall less pathological. Indeed, none of the measures in this study could predict parents’ ratings of their child’s pathology.

[75] Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun.  ...Studies evaluating this approach only included children who were at least 12 years of age https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf 

[76] 2.2. We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of estradiol and testosterone, respectively), but no earlier than Tanner stages 2–3.https://academic.oup.com/jcem/article/94/9/3132/2596324 

[77] https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. 

[78] https://www.ncbi.nlm.nih.gov/books/NBK138588/ [what the tanner stages mean]

[79] GnRH causes the pituitary gland in the brain to make and secrete the hormones luteinizing hormone (LH) and follicle-stimulating hormone (FSH). In men, these hormones cause the testicles to make testosterone. In women, they cause the ovaries to make estrogen and progesterone. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gnrh 

[80] When puberty begins, GnRH is secreted in a pulsatile manner by neuroendocrine cells in the hypothalamus and released into the hypophyseal portal system.33 GnRH binds to specialised cell plasma membrane receptors on the surface of the anterior pituitary gland, stimulating the release of luteinising hormone (LH) and follicle stimulating hormone (FSH). Notably, this pathway is identical in male and female individuals. These hormones, in turn, prompt the appropriate gonads to synthesise and secrete the steroids (testosterone in male individuals and oestrogen and progesterone in female individuals) that lead to the development and maintenance of sexual characteristics and function.33 Oestrogen and testosterone are then circulated back to the hypothalamus and the pituitary gland, and regulate further LH and FSH secretion.34 https://sci-hub.tw/10.1016/S2213-8587(17)30099-2

[81] https://www.ncbi.nlm.nih.gov/pubmed/3109919 paper from 1987: The effect of treatment with an LH-RH agonist (Buserelin) on gonadal activity growth and bone maturation in children with central precocious puberty.

[82] http://sci-hub.tw/10.1210/jcem.79.2.8045943 The isolation and subsequent synthesis of GnRH in the early 1970s allowed for the subsequent development of agonists and antagonists of GnRH.

[83] https://www.ncbi.nlm.nih.gov/pubmed/25501098

The results suggest GnRHa therapy may have a positive effect on final adult height in girls with early puberty, while adding GH to the treatment may suggest more advantage.

[84] https://www.ncbi.nlm.nih.gov/pubmed/24719967 GnRHa therapy does not appear to induce polycystic ovary syndrome or have long-term negative repercussions on either bone mineral density or body composition. 

[85] https://sci-hub.tw/10.1016/j.jpeds.2006.05.026 mean treatment time: 25 months. Followed them for 33 months after that. “Although the size of the sample examined does not allow us to reach conclusive results, our data seem to demonstrate that neither early puberty nor its treatment significantly affects normal adult function of the pituitary-gonadal axis.” looked at reproductive functioning mostly

[86] https://sci-hub.tw/https://doi.org/10.1210/jcem.84.12.6203 4.4 +/-2.1 yr treatment, looked at patients at age 16.7 +/- 2.6 yrs. “No negative effect on bone mineral density and reproductive function was seen. Treatment neither caused nor aggravated obesity.””

[87] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5290107/ The results of this study suggest that GnRH agonist treatment has no adverse effects on the reproductive function.

[88] Study including boys https://academic.oup.com/jcem/article/90/3/1371/2836690 Mean treatment durations were 3.8 ± 2.0 and 4.1 ± 2.5 yr, and posttreatment follow-up durations were 3.5 ± 1.3 and 2.6 ± 1.1 yr for girls and boys, respectively.  … Serum testosterone levels reached normal adult level in all boys… In conclusion, long-term leuprorelin treatment for children with CPP improved AH and had no adverse effects on recovery of reproductive function.

[89] For trans https://sci-hub.tw/10.1016/j.bone.2016.11.008 did see decrease in bone mineral apparent density but after two years of cross sex hormone treatment, the bone mineral density bounced back, somewhat. [Note: A review says this article shows that bone mineral loss “successfully reversed after two years of cross-sex steroid treatment” but the paper actually says: “However, pre-treatment Z-scores were not reached in most transgender adolescents after 24 months of treatment with CSHT.”  So “successfully reversed” sounds like an overreach.]

[90] https://sci-hub.tw/10.1007/s11154-018-9457-0 Puberty suppression is the reversible first step of endocrine medical treatment in transgender youth, and allows for two very important aspects of transgender management. … lists some common short term side effects: Most frequently, adverse effects involve problems with the injection site itself.

[91]  In subjects with precocious puberty, spontaneous pubertal development has been shown to resume after patients discontinue taking GnRH analogs (93 https://academic.oup.com/jcem/article/102/11/3869/4157558 

[92]Good study on safety for trans folks:  http://sci-hub.tw/10.1016/j.jsxm.2016.05.004.  Triptorelin effectively suppresses puberty in gender dysphoric adolescents. These data suggest routine monitoring of gonadotropins, sex steroids, creatinine, and liver function is not necessary during treatment with triptorelin. Further studies should evaluate the extent to which changes in height SD score and body composition that occur during GnRHa treatment can be reversed during subsequent cross-sex hormone treatment.

[93] http://sci-hub.tw/https://doi.org/10.1210/jc.2014-2439 “This suggests that the BMD was below their pretreatment potential and either attainment of peak bone mass has been delayed or peak bone mass itself is attenuated.” BUT another study found transwomen had lower bone health even if they had gone through puberty, and thought it could be that they’re living a “less active lifestyle.”   https://sci-hub.tw/10.1016/j.bone.2013.01.039 so hard to tell if it was the puberty suppressors. Also: “We used natal sex as a reference for aBMD z scores because the size and quality of cortex of the bone is determined during puberty and adolescence” and men have higher scores than women

[94] https://sci-hub.tw/https://doi.org/10.1210/jc.2017-01658 Pubertal suppression is fully reversible, enabling full pubertal development in the natal gender, after cessation of treatment, if appropriate.

[95] And see this case report of a 35 year old trans man who did puberty suppression and cross hormone treatment. (So probably an early adopter.) “B’s lipid profile did not deviate from the normal reference values and the BMD measurements showed values well above the 50th percentile for biological females. Compared to reference values for white males, his BMD values were around the 50th percentile.”

[96] We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 yr, using a gradually increasing dose schedule of cross-sex steroids.

2.6 We suggest deferring surgery until the individual is at least 18 yr old. (2 ⊕○○○)

[97] https://e-apem.org/journal/view.php?doi=10.6065/apem.2016.21.4.185  [starting hormones earlier is being studied] While age-specific guidelines for subsequent interventions are not delineated in the WPATH SOC, the ES guidelines suggest that cross-sex hormones can be initiated at about the age of 16 years (the legal age for medical decision-making in some countries), while surgical procedures (with the exception of mastectomy) should be deferred until the individual is at least 18 years of age4).

[98] According to the Endocrine Society’s clinical practice guidelines, transgender adoles- cents should have their endogenous puberty suppressed until 16 years of age, after which cross-sex hormones may be given.

[99] One important recommendation is the use of gonadotropin hormone releasing hormone analogues (GnRHa) to suspend the endogenous puberty of gender dysphoric youth in the early stages of puberty (Tanner 2–3) with the addition of cross sex hormones at about the age of 16 in order to induce masculine or feminine features that more closely align with the young person’s internal experience of gender.

[100] “...when cross-sex hormones were introduced (mean age, 16.7 years) ..” http://pediatrics.aappublications.org/content/134/4/696 

[101] https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf 

[102]http://sci-hub.tw/10.1002/phar.1487 In adolescents, CSHT and SRS are commonly delayed until later in adolescence when informed decisions regarding the use of CSHT, which can cause irreversible physical changes, can be made.

[103] https://www.researchgate.net/profile/Colton_Keo-Meier 

[104] http://tau.amegroups.com/article/view/11807/12219 

[105] Collectively, the eight runners were much slower in the female gender; slow enough, in fact, that their age graded performances were almost identical to their male AGs. Two of the runners had higher average AGs in male gender than in female gender, while one runner had higher female AGs than male ones. The changes in the age grades of these runners mirrored changes in their training habits.

[106] https://sci-hub.tw/10.1016/j.jcte.2015.02.003  The greatest health concern for HT in transgender women is venous thromboembolism.   HT among transgender men appears to cause polycythemia. Both groups experienced elevated fasting glucose. There is no increase in cancer prevalence or mortality due to transgender HT.

[107] https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf see table on page 40

“Use of oral estrogen, and specifically ethinyl estradiol, appears to increase the risk of VTE” pg48

[108] https://journals.lww.com/greenjournal/Fulltext/2014/12000/Transgender_Men_Who_Experienced_Pregnancy_After.9.aspx Pregnancy, delivery, and birth outcomes did not differ according to prior testosterone use  Birth weight HT: 2914g ; No HT: 3490g

[109] https://sci-hub.tw/10.1177/1753495X15612658 for discussion on previous citation

[110] Email: So the one thing we do know is that there's no way your gametes will work unless you go through puberty (of your assigned gender). Do I have that right? [source] Right .. but whether that could still happen or be made to happen .. later remains a question.

[111] Email, source: I've worked with parents and youth who were not given this information and then when they got a little older and realized they could not have biological kids (unless they went off the blockers for a period of time) they were quite distraught. MH: For both transwomen and transmen, they need to go through puberty to be fertile. We have no evidence that anyone who has gone straight from puberty suppressors to hormone therapy has been able to sexually reproduce.  Do I have that right? [source]: That is correct. Reproductive medicine people are working on this - hoping there will be options in the future, but at this point, it does not appear possible.

[112]  Currently it is not possible for children who have not undergone natal puberty (and who may have used gender affirming hormones) to preserve gametes. http://transhealth.ucsf.edu/trans?page=guidelines-fertility 

[113] https://mdpsych.org/wp-content/uploads/2016/04/Dr.-Pine-Handout-Version.pdf  Gender Dysphoria in Children and Adolescents: Medical Considerations presentation by Elyse Pine, MD Staff Physician “No current options for fertility preservation “ if blockers are taken before “significant pubertal development”There are options to preserve fertility – Must be physically late in puberty • Sperm production occurs, on average, at age 13‐14, with Tanner III‐IV testes and II‐III pubic hair • Egg maturation occurs, on average at age 12‐13,

[114] https://journalofethics.ama-assn.org/article/transgender-reproductive-choice-and-fertility-preservation/2016-11 At this time, there are no standard methods available to prepubertal or pubertal adolescents to preserve sperms or eggs.

[115] https://sci-hub.tw/10.1210/jc.2009-0345 You can harvest sperm between PB and HT : “...sperm production can be initiated after prolonged gonadotropin suppression, before estrogen treatment.”- but may take 6-12 months of spontaneous gonadotropic recovery before start of estrogen to harvest the sperm.

[116] A 17 year old boy harvested his eggs before initating androgen therapy https://sci-hub.tw/10.1097/AOG.0000000000002036 

[117] https://sci-hub.tw/10.3109/09540261.2015.1084275 Although there are only few studies that have investigated the desire of transgender people to have children, they all conclude that approximately half of trans women (male to female transgender persons) and half of trans men (female to male transgender persons) wish to have children (De Sutter et al., 2002; Wierckx et al., 2012a; Wierckx et al., 2012b).

[118]https://www.tandfonline.com/doi/full/10.1080/0092623X.2017.1326190?scroll=top&needAccess=true The majority of trans women had undergone a vaginoplasty, and some also received mamma augmentation. Other feminizing procedures included thyroid cartilage reduction, facial feminization surgery, and vocal cord surgery. The vast majority of trans men had undergone mastectomy and/or uterus extirpation and ovariectomy, and a minority received penis construction (phalloplasty or metoidioplasty). (see figure 1 for numbers)...None of the respondents reported major regret. Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009.

[119] https://onlinelibrary.wiley.com/doi/abs/10.1111/J.1365-2265.2009.03625.x We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). 

[120] https://link.springer.com/article/10.1007%2Fs10508-014-0453-5 Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. 

[121] https://www.sciencedirect.com/science/article/pii/S1748681507005700

Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

[122] https://onlinelibrary.wiley.com/doi/full/10.1046/j.1464-410X.2001.02323.x

Male‐to‐female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender‐transforming surgery.1995 to July 2000

[123] https://link.springer.com/article/10.1007/s11136-010-9668-7 Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

[124] https://link.springer.com/article/10.1007/s13669-017-0203-5

Most patients are satisfied with the functional and esthetic outcomes of vaginoplasty, but sexual dysfunction may be common. The risk of regret following vaginoplasty seems to be low, and certain risk factors for this unfavorable outcome have been identified.

[125] https://sci-hub.tw/10.1111/j.1600-0447.1998.tb10001.x The results showed that 3.8% of the patients who were sex reassigned during 1972‐1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non‐core group of transsexuals.

[126]https://sci-hub.tw/https://doi.org/10.1016/j.jsxm.2018.01.016

Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret. This study included kids and adolescents. Doesn’t look at regret specifically with kids, but does look at out of the kids who started puberty suppressors, how many of them stopped taking them, and that was only 1.9% in table 1.

[127] Non-treated transgender people have a nearly 4-fold increased risk of depression. https://www.sciencedirect.com/science/article/pii/S0165032717324400 

[128] Compared with the general population transgender people had a nearly threefold increased risk of probable anxiety disorder (all p < .05). https://www.tandfonline.com/doi/abs/10.1080/15532739.2016.1258352

[129] 2015 National Transgender Discrimination Survey: “Forty percent (40%) have attempted suicide in their lifetime, nearly nine times the rate in the U.S. population (4.6%).” and the 2011 version of this survey found: “A staggering 41% of respondents reported attempting suicide compared to 1.6% of the general population…” 2015 report included 27,715 respondents and the 2011 report included 6,456 transgender people from around the US.

[130] http://sci-hub.tw/10.1017/S0033291711002340 See table 1. Lifetime prevalence of suicide attempt varied by race/ethnicity but was pinned at 4.58% overall.

[131] 2016 meta-analysis of of studies on transgender suicide and self harm rates found: “In spite of the methodological limitations of many studies, all the studies investigating suicidality in the trans population have found considerable higher rates of self-injury in the trans population compared to cisgender people, primarily among young trans men.”

[132] For example: Although suicide rates vary widely among individual tribes, it is estimated that 14 to 27 percent of AI/AN adolescents have attempted suicide.2123 

[133] http://pediatrics.aappublications.org/content/pediatrics/134/4/696.full.pdf  After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Wellbeing was similar to or better than same-age young adults from the general population.

[134] https://www.hrc.org/resources/a-national-epidemic-fatal-anti-transgender-violence-in-america-in-2018 

[135] https://www.liebertpub.com/doi/abs/10.1089/lgbt.2015.0111 Overall, 42.3% of the sample reported a suicide attempt and 26.3% reported misusing drugs or alcohol to cope with transgender-related discrimination. After controlling for age, race/ethnicity, sex assigned at birth, binary gender identity, income, education, and employment status, family rejection was associated with increased odds of both behaviors. Odds increased significantly with increasing levels of family rejection.

[136] https://www.sciencedirect.com/science/article/pii/S0272735817304208