This is a translation of this Dutch article that appeared in the Dutch paper De Gelderlander
“NIJMEGEN – Nijmegen has a “transgender center” since spring 2020. Children who feel that they are not of the right gender can go there. They receive psychological help, puberty blockers or hormone treatments to make their bodies change sex. The treatment is relatively new, has been called “experimental” by some and has now been banned in the United Kingdom.
At the Radboudumc Amalia children’s hospital in Nijmegen, they actually had no plans to start a transgender clinic. Until the ministry called to ask if they could not help Amsterdam UMC, because of the long waiting list for transgender care, which spanned up to three years.
The Radboudumc, which includes the children’s hospital, agreed. In the first year, only children were treated. From Monday, adults can also visit the Nijmegen transgender center.
Hedi Claahsen, head of the Radboud Expertise Center Sex & Gender, sees children who have been on a waiting list for a long time. “That’s why they are already far into the process. They know what they want. They come to us with a direct question. For example, that they want to go from a girl to a boy, or vice versa. We will then take a step back. To the beginning. Who are you? What other things are going on in your life?”
The task of medical psychologist Chris Verhaak is to further examine the boys and girls. After a series of conversations, more should be clear. “How long has a child wanted to be a boy or a girl? How comfortable is the child in his or her own skin? Are there other health questions? They can also influence the gender that a child experiences.”
Pressure from long waiting lists
This reluctance to grant patients’ wishes too quickly is not only found in the Nijmegen transgender clinic. Thomas Steensma of the Center of Expertise on Gender Dysphoria in Amsterdam feels the pressure of the long waiting lists, but, like the doctors in Nijmegen, does not want to be rushed. “Then you could get situations like the ones that are happening in Great Britain now.”
Several employees and administrators of the Tavistock and Portman NHS Foundation Trust in London, where children can undergo a transition, no longer support their work. It became clear through leaked reports that administrators and employees of the mental health organization believe that children are allowed to change their sex too quickly. Nor would there be enough evidence that the treatment works in the long term.
The court of justice in London also ruled in January that children under the age of 16 cannot foresee the consequences of hormone treatment. All treatments with young people have been put on hold there.
Steensma does not endorse the judgment of the British court. According to him, there are children who can oversee the consequences. “But that’s an individual process. You can’t compare individuals with one another. We are not saying that hormone treatments are good for everyone. We would also never say that they are not good for anyone. We make the assessment per person. ”
In the Netherlands, the discussion about puberty blockers and sex-changing hormones is much more balanced, says Steensma. “In Great Britain you now see the focus on the possible disadvantages of the medication. In the Netherlands, it is much more about the assessment: what can you do medically to reduce someone’s psychological suffering? You can say, as long as nothing is known, we will not do anything. We say: as long as we do not see any harmful effects, we will continue. We are confronted with young people who are in enormous trouble. Some of them will even order medication on the internet or commit suicide.”
Children who suffer from “gender dysphoria”, feeling severe dissatisfaction with their sex, can be given puberty blockers in the Netherlands from the age of 11. These ensure that a child’s body does not develop further as a man or woman. “You mainly buy time with this,” says Steensma. “The child then has a little longer to find out what is needed together with doctors and the parents. That’s not always a complete sex reassignment.”
Often you don’t have to change your body completely
Claahsen, of the transgender center in Nijmegen, notices that small adjustments are sometimes enough. “Not having your period anymore can sometimes be an enormous relief for someone. Or an adjustment to the face. It has long ceased to be about what someone has in their pants. In the past, you were allowed to have your desired sex on your passport when you had actually undergone an operation. That is no longer the case. Even if you still have the body of a woman, you can already have it listed in your passport that you are a man. That has taken the pressure of an operation off many transgender people.”
If a child remains convinced that the entire body should change sex after using puberty blockers, they can receive cross-sex hormones from the age of 15. A girl who feels like a boy, will then, for example, grow a beard. A boy who is taking these hormones, develops breasts. Before these hormones are administered, children need to be aware of the fact that their fertility may be negatively affected.
Consequences not to foresee
According to the British court, these consequences cannot be foreseen by a child. Steensma thinks that he and his doctors are having that conversation in a thorough manner. “That doesn’t happen overnight. This is a process of years that you enter with someone. You work towards it, we also use those puberty blockers for that, to win some time. But yes, the fertility of an adolescent remains a difficult issue. That’s just how it is.”
Aike Pronk of Transgender Netwerk Nederland points out that young transgender people’s desire to have children is often just as important as the desire for a transition. “But the urgency to start a transition is often very high among young people. It is then difficult for them to bear that their desire to have children becomes a potential problem. It is then a matter of choosing between two evils. ”
According to Pronk, prescribing puberty blockers or other hormones should also be something a “regular” pediatrician is able to do. It would significantly shrink the waiting list for transgender healthcare.
This is absolutely not an option for the aforementioned doctors from Amsterdam and Nijmegen. Steensma is perturbed by the method of some clinics and practitioners in America, for example, where puberty blockers seem to be the solution to everything. Without proper guidance, without proper research. But also in his own clinic there is a hunger for more information, more knowledge and experiences with transgender care. The treatments will continue in the meantime, because that is how medical research works, Steensma explains. “We do that research on a moving train. We are constantly evaluating what we are doing.”
The policy of his Center of Expertise on Gender Dysphoria at the Amsterdam UMC is based, among other things, on a major study from 2011 by Annelou de Vries. Steensma contributed to this himself. The research showed that a transition usually works out well in psychologically stable young people. There is no long-term research on this group yet, but shortly after the transition, the young people felt better.
Steensma notes that he is also critical of the earlier research, because there has been a sharp increase of registrations since 2013. Especially of children who were born as girls but feel like boys. “That needs research. Can our research from back then still be applied to the group of young people who are registering for treatment now? And why are so many girls suddenly experiencing dissatisfaction with their sex? That really needs to be investigated.”
Aike Pronk of Transgender Network Netherlands would also like to see more research. “But the studies that are available show a positive image of people coming out of a transition. We hope to confirm that image with new research.”
Pronk believes it is important that no one is denied medication until then. “The fact that little research has been done should not mean that someone does not receive medication for that reason. In medicine this is just the way it works, that treatments keep getting better over the years. What we know from the little research out there now is that the treatment is effective. Obviously, taking into account the desire to have children is important, but letting a group of young people go through puberty in a body in which they do not feel well is far more harmful, even with suicidal thoughts as a result. This can be prevented with timely treatment.”
Hedi Claahsen and Chris Verhaak of Radboudumc discuss what they think is the right thing to do every day. The dilemmas are brought up with moral deliberation. When are sex reassignment drugs a good idea, how can you be certain the child will know for sure?
“It cannot be measured”, says Claahsen. “It is not something you can see somewhere. That’s the hard part. Of course we believe everyone we see for treatment. That is our job. At the same time, we must deal with it professionally. Yes, people have a right to self-determination, but it requires a certain expertise of doctors. You do not remove someone’s appendix because he or she asks for it either. As a doctor you go on an investigation. We explore that too. We explore what is going on together with the client. So that everyone eventually becomes or remains who he or she is. ”
Alex Lambeek (16) from Deventer was born as a girl, but feels like a boy. He is being treated at the transgender center in Nijmegen and will soon be receiving hormones that will further transform his body into a man.
“At the beginning of puberty I felt something strange. My body changed from a girl to a woman. That didn’t feel right. I suddenly saw myself in the future as a woman, and that image was not correct in my head.
“I had never thought about that before. As a child I could wear boyish clothes and play football. Playing with barbies or doing other girl things was nothing to me. I thought that was fine, I didn’t have to.
“I now have a group of friends that are all girls. When I see them doing makeup and having long hair, I know I don’t want to be like that. When I watch a guy play sports, I feel the opposite. I want to be that way too! When I first heard about transgender people in high school, I realized, that’s what I am.
“I told my parents. They were very open and accepted my story. They did ask, “Aren’t you just a really tough girl?” I understand that question, but I don’t see my future as a woman. They did not suspect that I am transgender. Because of my tough character they had wondered if I might be a lesbian. That’s not the case, I like guys. So now that I am a boy, I am gay.
“When I was 14 I was put on the waiting list for transgender care. It took a year and a half before it was my turn. In the meantime, I changed my name to “Alex” and started living as a boy. I was no longer seen as a little girl but as a tough, adolescent boy. That felt very nice.
“In March last year I was allowed to start at the new transgender clinic in Nijmegen. Ideally, I wanted to start medical treatment immediately, but it doesn’t work that way. First conversations followed. I understand that, but I thought it was tough. After such a long wait, you want to start preventing puberty. After six months I said that I really wanted to start with the puberty blockers, and then that was allowed.
“I have been on puberty inhibitors for a few months now and in the spring I can start with the cross sex hormones. Then I get testosterone, which will give me beard growth, my breasts shrink and my voice will drop.
“There are times when I have doubts. Am I really transgender? Those are the moments of uncertainty that come with it. Once I was on the puberty blockers for a month, I felt more secure. “This is what makes me feel good,” I felt that strongly.”
Desire for children
“Starting testosterone in the spring is a new phase. I’m really looking forward to that. I know it can affect my fertility. That is why I already had to think about my desire to have children. I had interviews with a gynecologist and a pediatrician. I did get a lot of information, but it was still difficult to think about it. How can I know at the age of 16 whether I want children later in life? What I do know is that my desire to become a boy is currently stronger.
“I could have eggs or my ovary frozen, but I won’t decide until later. When I am 18 I can still do that. I do not know exactly whether those eggs will still be good as a result of the administered hormones, but I think there is little chance that they will be damaged. And otherwise I can always adopt children, that would be fine with me too.
“There are people who think that teenagers cannot be sure enough whether they want to change sex. As a teenager you discover who you are and you spend a lot of time doing self-examination. So you know very well what you feel. ”
This article has been translated into English. The original Dutch version can be found here: https://www.gelderlander.nl/nijmegen/hormonen-geven-aan-transgenderkinderen-is-omstreden-maar-volgens-artsen-toch-soms-nodig-het-is-kiezen-uit-twee-kwaden~ab8da190/