The dilemmas of treating Spain’s teenage transsexuals

Drugs allowing young people to delay decisions on their gender aren’t available in all regions

Las Palmas de Gran Canaria - 29 Sep 2014 - 14:42 CEST
Lola and her family in their home in Gran Canaria.
Lola and her family in their home in Gran Canaria.Quique Curbelo

Maisie says she was bathing her four-year-old son when he told her for the first time that he was a girl and wanted to behave like one. A psychologist told Maisie and her husband not to worry and allow the child to play and dress as he wanted. When he was older, they would see. He was happy at home, where he wore his mother’s clothes and always asked for dolls at Christmas time. But in the street, he continued to dress and behave like a boy. Eleven years on, Lola, now a woman, says she was scared a lot of the time: “I was afraid because I didn’t really understand what was happening to me, and I was afraid that people would reject me; but at the same time, pretending to be somebody different was painful, it was like disguising myself when I went out.”

But eventually, through a friend, she met other people with similar experiences. “I understood that I was transsexual,” she says. At the age of 11, she decided to start calling herself Lola. Her parents accepted the decision, having supported her over the previous seven years. Her father, a social worker, was arguably better prepared than most to help the family deal with such a difficult situation.

Lola says that while the decision to accept her condition was a “liberation,” she had a tough time at school. “I felt that nobody could love me for who I was,” she says.

I am very happy, and in large part, that is due to the inhibitors” Lola, aged 15

As adolescence approached, Lola became concerned about any physical sign of masculinity: I couldn’t imagine myself with facial hair, and whenever any hair sprouted, I would wax it off.”

At this point, her parents requested professional help. A pediatrician recommended using hormone blockers, which inhibit the orders the brain sends to the body to produce sex hormones. The idea is to hold off development until the minor is old enough to decide whether to commit to definitive hormone treatment, which in some regions is at the age of 16, and in others is 18. Such treatment has been available in Spain for five years, and is reversible. If at any time Lola, who is now 15, were to stop taking the blockers, her body would begin developing masculine sexual features, says her endocrinologist, Javier Martínez.

To be able to continue the treatment, Lola needs a psychiatric report establishing her status as a transsexual. For many families, this is the most difficult moment: at such a young age, how can they be sure that their son or daughter is really transsexual? Psychiatrists explain the parameters they use: aversion on the child’s part to their genitals; discomfort at being referred to by the gender they have rejected; and above all, the persistence of behavior patterns that conform to the sex the child expresses.

In Lola’s case, a psychiatrist confirmed that she was transsexual. After an examination by an endocrinologist, she began taking hormone blockers at age 13 under the national health service. During this time, she has continued to grow, but without developing sexually. Her quality of life, however, has improved hugely: “I am very happy, and in large part, that is due to the inhibitors,” she says.

At such a young age, how can parents be sure that their son or daughter is really transsexual?

Lola lives in the Canary Islands, where, with parental consent, hospitals are authorized to use hormone blockers. But the situation varies from region to region. Spanish law says that hormone blockers can only be used in cases where puberty begins too early, but not in transsexual cases such as Lola’s. The Health Ministry says each regional government must decide on its own policy in this regard. In the Canaries, Andalusia, Asturias, Navarre, Castilla y León and Valencia, adolescents can be given hormone blockers. But in Extremadura they must be aged 14 or over, and in Murcia, Cantabria and the Balearics, they must be aged at least 16. The procedure in each case is the same: a pediatrician begins the process, and then refers the minor to a psychologist or psychiatrist, who confirms their status as transsexual, and finally, an endocrinologist certifies that there is no reason not to use hormone blockers.

But the Basque Country, La Rioja, and Aragon have no laws regulating the issue. In Galicia, hormone blockers are only available to over-18s.

Madrid is preparing legislation to help young people in this situation, and whether to provide access to hormone blockers is one of the issues under debate. The Popular Party-controlled regional government of Madrid has previously rejected proposals to provide hormone-blocking treatment and new identity cards in the chosen sex of the minor: for many young people in this situation, something as simple as applying for a bus pass is a major obstacle.

More information

There is no register of transsexual minors in Spain. A parent-run association called Chrysallis helps around 150 families, and says it receives more and more requests for information each week. Ana Belén Gómez, a psychologist with the PIAHT, an information program for homosexuals and transsexuals, says there are probably many more children who are hiding their condition.

Patrick is aged 12, and lives in Benasque, a small town in the Pyrenean province of Huesca, which is part of the autonomous region of Aragon. His mother, Natalia, says that when she asked her local health authority for information about transsexuality, she was told that there were no specialists available.

Everybody who knows Patrick says that despite having female genitalia, he is a boy. So far, he has enjoyed a trouble-free childhood in that capacity. But with the onset of puberty, Patrick’s parents are concerned because their regional government has no rules regarding treatment for transsexual adolescents.

Patrick’s parents have had to secure hormone blockers from a private clinic in Barcelona, and he began treatment in July. “I am paying for treatment that other children receive free of charge,” says Natalia, his mother, adding that the cost of the medicines and travel so far has been €2,500. She is among the many mothers arguing in favor of national legislation to help children like hers: “These children need to be left alone to grow up quietly, like all children,” she says.

Growth and fertility

The relationship between hormone blockers and growth is the subject of considerable debate among healthcare professionals. Endocrinologists such as Itxaso Rica, the head of a pediatric unit in Barakaldo in the Basque Country, who have experience of using them with children who have begun puberty early say they have no impact on the final height and weight of their patients. But things are different in the case of transsexual adolescents: the age of patients and the duration of treatment are different, and blocking hormone development can delay growth.

Rica says that even though it is not possible to be sure whether hormone blockers do influence growth, it is not a serious problem. “It is necessary to check each case on an individual basis to be able to apply the right medicines,” she says.

Javier Martínez, Lola’s endocrinologist, says delaying puberty prolongs the growth phase into early adulthood. Another side effect can be sterility. Martínez explains that this is still not fully established. “By blocking the production of sex hormones, we bring on temporary infertility, but it disappears when treatment is stopped.”

This is a controversial topic, because many adolescents go straight from taking hormone blockers to a definitive hormone treatment that can induce permanent sterility some time between the ages of 16 and 18, depending on the region in which they live.