Introduction
This article discusses the treatment of transsexual boy-to-girl children.  When allowed to, such children are almost always able to rapidly and successfully assimilate themselves in to society as a female, this alone is enough to differentiate them from the experience of most transsexual women who transition when an adult.

It is also perhaps necessary to distinguish between intersexed infants, which in some cases are assigned a gender contrary to their genetic sex, and gender identity dysphoric (GID, aka transsexual) children.  While very young intersexed infants have no say in their sex assignment or reassignment (which is usually done before they are 24 months old), transsexual children consciously reject the gender in which they are being brought up at some point between two years old and puberty.

Debbie, a young transgirl from the UK

Since the 1960's - when Dr John Money, a physician at Johns Hopkins University, made the medical community at least recognise transsexuality - there has been an ever increasing incidence of Male-to-Female (MFT) of reported GID cases and requests for treatment across all age groups.  However in recent years the growth in reported cases among teenagers, particularly boys, has been extraordinary. 

No one compiles official statistics on transgender youths, but everyone agrees that their numbers are rising very quickly.  For example in 1999 alone, the number of transgender'ed people under 22 in the "gender reassignment" program at New York's Michael Callen-Audre Lorde Community Health Center tripled!  Undoubtedly this is partly the result of increased access to information.  A child today with 'gender dysphoria' - the catch-all term for disconnect between body and gender identity, will almost certainly have heard about transsexuals by the time they reach the critical point of puberty.  Many children with GID problems learn about transsexualism from TV shows and documentaries and then go on-line, looking up anything and everything they can find out about transsexuality, and start to chat and email with other transsexuals. 

With the increasing awareness and more favourable publicity given to transsexualism, MTF children who in the past would have suppressed their female gender, or at least defer dealing with it openly until reaching adulthood, are now coming forward while still a child.   In most cases their families respond very positively and supportively, but occasions of outraged parents and internal family battles about how to deal with a would-be daughter will never cease completely. 

Unfortunately there continues to be a reluctance by the medical profession to pro-actively treat gender identity disordered children, even when they are diagnosed as "core" or "true" transsexuals.  However even the famous/notorious "Standards of Care for Gender Identity Disorders" (which very few medical professionals will dare not to conform to) has now advanced a tiny bit as regards young transsexuals as it reaches it's sixth edition.

While recent trends are somewhat encouraging, young transsexuals (under 20) seeking and obtaining medical help and treatment are still vastly outnumbered (10 or 20 to 1?) by their older counterparts - most of whom bitterly regret their years of delay.  Also, young transgirls tend to immediately go stealth after transition, and the girls pictured on this page are exceptionally brave about their transsexuality - or had little choice as they were out'ed by the media.

Willem, age 12 and Kristel (born Jeremy) age 11, for more information see Lynn Conway's site.

Sex Assignment 
A persons sex can be determined or judged by many factors, including:

1. Legal Sex:  In the UK the infamous ruling by Lord Justice Ormrod, irreversibly determined that this was the sex stated on the original birth certificate - although since 2004 the Gender Recognition Bill has overturned many aspects of this ruling.
2. Hormonal Sex:  Based largely upon male type testosterone plasma levels, or female type oestrogen and progesterone plasma levels.
3. Chromosomal Sex:  Male "XY" or female "XX" genes as determined by a karyotypic study (in rare cases there are other combinations).
4. Internal Sexual and Accessory Organs:  The presence of male (testes) or female (ovaries) gonads, and male (e.g. vasa deferens, ejaculatory ducts and prostate gland) or female (e.g. uterus, vagina, fallopian tubes) accessory organs.
5. External Sexual Characteristics:  Male (e.g. penis, scrotum) or female (e.g. clitoris, labia majora) appearing external genitalia, and other male (e.g. beard) or female (e.g. breasts) appearing secondary sexual characteristics.
6. Gender Role:  The sexual role a person lives in, and the sex they are perceived as being.  It has been defined as "A social status usually based on the convincing performance of femininity or masculinity".
7. Sexual Identity:  The sex a person identifies with and believes they actually are.  

It is quite possible for these factors to disagree and contradict, e.g. a post-operative transsexual person may well have a male birth certificate, a male karyoptype (XY genes), no internal female sex organs but female appearing genitalia and sexual characteristics, live as a woman and believe that she is a woman.

Factors 6 and 7 are commonly and unfortunately combined under the term "gender-role", but I prefer to keep them separate when possible.  A particularly confusing but frequent use of the word gender is in the phrase "Gender Re-Assignment Surgery"  (GRS).  It's essential to differentiate between a persons physiological sex (factors 4 and 5), and a persons social & mental gender (factors 6 and 7), surgery can't ever change the later and phrase "Sex Re-Assignment Surgery" (SRS) is a better, although still seriously exaggerating, description of what  surgery can achieve.  

Gender
For most children their legal, chromosomal and physical sex agree with their mental gender and preferred gender role.... but not always.  As already mentioned, children with gender identity problems are described as having gender dysphoria.

Establishing a gender identity is a process that most people take for granted, but that no one completely understands.   

Scientists and sociologists agree that traditional gender roles are in many ways socially constructed, e.g. girls learn to wear dresses and boys learn to wear trousers.  But no one seems to understand what makes a transsexual child raised in a male gender role embrace the female role as her own and vice versa.  Nor can anyone explain why many intersexed children raised as one sex eventually migrate back to the gender that their genetics or their prenatal hormonal environment would have predicted.

Bill Summers, a professor of medical history at Yale who has studied the science behind gender and sexuality says "You have to learn somehow what it means to be a boy or a girl.  You don't come born with this idea.  But enough people say, 'I always knew I was a boy but I was raised as a girl' that I can't doubt they have these feelings."

Summers points to the work of Dr John Money who became famous in the 1960s for recommending and surgically facilitating the transition of a young boy with a botched circumcision into living as a girl - the so called "John/Joan" case.  Money initially declared the gender re-assignment to be a success, but his work was later undermined when the girl grew up with a masculine gender identity anyway.  Summers notes that "the whole idea [was] that given hormone treatment and the right social environment, you can determine gender identity.  It's not really quite so simple."

The bottom line seems to be that sociologists and psychologists still don't know where gender identity comes from or why - but it is unlikely that either biology or society operates totally independently from the other.  The only current certainty seems to be that when a young child decides that they are a boy or a girl and this decision contradicts their supposed physiological sex, the result is much anguish and cost to the child, the parents and the medical profession.  

Young boy-to-girl transsexuals have few doubts doubts about their sex - they know that they are really female and unlike older transsexuals can usually easily pass as such.

Sexual Identification of Transsexual Children
It is important to note that many boy-to-girl "transsexual's" do not consider themselves to be transsexual - indeed they often actively dislike being called such - they just consider themselves to be girls.  The reality is that young transgirls often associate the word "transsexual" with TV documentaries featuring strange balding middle-aged men, married with children, who at the end of the programme still look, sound and behave like men wearing wigs,  dresses and too much makeup to their very discriminating eyes and standards.  Young transgirls simply can not relate themselves with these examples of transsexuality - their problems are totally different, and even passing is rarely one of them.

A key, if obvious, differentiator between transsexuality emerging in children and the far more numerous instances of it emerging in an adult is the pre-puberty age at which noticeable cross-gender behaviour appears in the former group.  According to one study, two thirds of transsexual boys are aware that they belong to the opposite sex and exhibit such behaviour" by age 5, and 77% by age 10.  Another study of 137 MTF transsexuals confirms these figures, finding 70% exhibited cross-gender behaviour before age 10, and another 20% before age 15. 

Riley (formerly Richard) "Grant", age ten, she has never doubted that she is a girl and transitioned when age 7. (USA)  Source: Heidi Gutman/ABC

For example Richard ('Richie') always wanted to wear dresses like his sister, when age two and a half his mother caught him trying to cut his penis off with nail clippers, saying "this doesn't go here".  At age 7 he was finally diagnosed as having Gender Identity Disorder, his parents changed her name to Riley Elizabeth and let her go to school as a girl - where she blossomed from a "sad confused little boy into a happy young girl".  The financial burden of Riley's medical care had been crippling, but her parents had no doubts - "seeing Riley's happy face now, it's worth every penny"

It seems that at least three-quarters of gender dysphoric children will eventually have sex re-assignment surgery (SRS). 

Jerke, a 10-year old transgirl from Holland.

If clinical testing finds that the following conditions apply:

1. onset of a desire to belong to the opposite sex before puberty

2. cross gender behaviour and social role without sexual arousal

3. dislike for one's own secondary sexual characteristics

then core transsexuality, commonly known as "true" or "primary" transsexuality, is likely to be confirmed and appropriate sex-reassignment treatment should be started.  

However there still remains considerable reluctance by the medical profession to supportively treat a physically normal boy with gender identity problems - a boy who's adamantly insistent that he's really a girl.  The sex re-assignment of babies and very young boys became medically acceptable in the 1970's and 1980's (indeed, perhaps too common) - but has since become discredited and unfortunately there has been a carry over affecting young transsexuals.    It seems to often require courageous and forceful parents before doctors will medically facilitate the transition of a minor.

Suzannah Fleming, age 6 (inset) and now.  She started hormones age 12 with the brave assistance of her mother - a registered nurse.

Parents
An understandable reluctance to "come out" to one's parents remains probably the greatest single obstacle to the early and successful treatment of many transgirls.  On the other hand, things do seem to be improving, and television and the Internet is playing a key role in this - these days most transsexual children first learn about "transsexuality" from TV programmes, relating to this condition they - and often their parents - seek further information via the Internet (now an extraordinarily valuable resource) and from books.

Danielle (formally Daniel) Gomez (Mexico/USA) had SRS at age 17, while still at High school.  Her supportive mother has written a book about Danielle's journey to womanhood.

It is impossible to underestimate how important the understanding and support of parents is for a young transsexual her eventual success in life.  It is also difficult to underestimate how much emotional strain having a transsexual child can impose on his/her parents.

Many parents become a pillar of support and understanding, indeed there are many instances of parents going to extraordinary lengths and expense to aid their new daughter - for example moving house so they can go to a different school and avoid anyone who knew them as a boy. 

In another positive example, Jamie never felt herself to be a boy, and when at age 11 she finally told her parents "You think that I am a boy, but I am a little girl!", they accepted her choice and she is now living very happily and confidently as their daughter.

20 year old Rachel transitioned when 17, but still visits her parents as their son Daniel. (UK)

On the other hand, there are also instances where the child tells the parents and the result is a nightmare of arguments and pressure.  Rachel (formerly Daniel) describes how when she told her parents at age 17: "They didn't shout at me but the conversation was very heated.  Mum got upset - although she said she'd guessed a while ago - and Dad was annoyed.  They both said they didn't want me to dress up in the house and that I'd always be Daniel to them.  ...  My parents have been good to me, but they'll always see me as their son."

Now finally transitioned, for many years Amy (shown age 19) received psychiatric treatment to "cure" her gender dysphoria.

Rachel is actually luckier than many girls.  Enforced visits to a suitable psychiatrist (suitable for the parents at least) to treat the child's gender disorder are common.  Perhaps in a few cases a "cure" is achieved, but more commonly the child suppresses his/her transsexuality, and if he persists then an eventual total rejection by one (usually the father) or even both parents may well occur.  For example, Brazilian Roberta Close was  disowned by her father, and only reconciled years later.  While now a successful model and actress, for several years in her teens Roberta descended in to the seedier side of life that all too many transsexual women go through in order to earn a living.

Often transsexual children feel unable to tell their parents about their feelings and needs.  This usually means that a public admission of their transsexuality is deferred to adulthood - and the delay is always much regretted.  But also the resourcefulness of children should not be underestimated.  For example, one text book (Man and Woman, Boy and Girl) describes how a woman secretly obtained and took hormones while still a young teenage boy.  Her concerned parents eventually took her to hospital for tests to help determine the cause of the resulting physical changes, but she had had enough warning to stop and let her system clear.  The doctors concluded that the changes were spontaneous and natural (some degree of gynaecomastia - male breast development - is quite normal in mid-puberty boys), and told the parents not worry.  
 

Maité (formerly Alexandre) Schneider from Brazil started hormones age 18, but has not yet had surgery. Breaking all the guidelines Marilia (formerly Errolclaud) Gabriela, also from Brazil, started hormones at age 13.  She had SRS at 22.

Medical Guidelines for the Treatment of Transexual Children
The widely followed HBIGDA Standards of Care of Gender Identity Disorders, a document which has previously (and increasingly controversially) been against the treatment against the hormonal treatment of under 16's, has relaxed its rules somewhat in the latest (2001) Version 6.  It now states that:

"Adolescents may be eligible for puberty-delaying hormones as soon as pubertal changes have begun. In order for the adolescent and his or her parents to make an informed decision about pubertal delay, it is recommended that the adolescent experience the onset of puberty in his or her biologic sex, at least to Tanner Stage Two."  [on average this means about age 11 for biologic females, age 12 for biologic males]  .....

"Adolescents may be eligible to begin masculinizing or feminizing hormone therapy as early as age 16, preferably with parental consent. In many countries 16-year olds are legal adults for medical decision making, and do not require parental consent. ....

"Any surgical intervention should not be carried out prior to adulthood, or prior to a real-life experience of at least two years in the gender role of the sex with which the adolescent identifies. The threshold of 18 should be seen as an eligibility criterion and not an indication in itself for active intervention."

Although still not coming out in favour of starting feminizing hormone treatment at a normal puberty age and delaying any sex change surgery until at least age 18, the standards do at least now allow the treatment of very young adolescents with puberty-delaying hormones and thus help prevent the socially and mentally disastrous development of normal male [secondary] sexual characteristics and appearance in an under-16 MTF school girl.

If a boy is diagnosed as a transsexual then a failure to immediately start treatment is not only deferring the inevitable in the vast majority of cases, but is doing so at a considerable cost to the child's future as a girl and woman.  It's indisputable that the earliest possible transition and pre-puberty hormonal and surgical treatment will offer most boy-to-girl's massive psychological and physical benefits.  

Early transition and commencement of treatment and transition  will permit the transsexual boy-to-girl a female childhood, a normal puberty (excluding menstruation) and allow her to enjoy her teenage years as a young woman.   It's an absolutely priceless experience if a transsexual girl goes through her adolescence and growing-up as a female, with a circle of same-sex girl friends.  It's a period of time when her personality, identity and attitudes are forming, and the stage for the rest of her life is being set.  She will have irreplaceable girlish memories and social adjustments that a transition later in life can never give her.  Her life experience will be much more like that of other women, she will be able to talk more easily about parts of her past, her school days, and even have photo's to show her future boyfriends.  For many girls, denying these experiences to her and enforcing an unwanted male gender is simply a disaster.

Transwoman Monica Morten, now in her mid-20's, doing her make-up.  Girls practice this from as young as 2, and it presents an immense challenge to the about the transition boy-to-girl or man-to-woman.  Their make-up is always vastly better a year after transition.

One successful transsexual woman 'Anna Taylor' describes her early experiences: "It never occurred to me that I was a boy. I just wondered why I had something extra. I had sessions with a child psychologist and my parents were told to bring me up neutrally.  My mother tried, but my dad would slap me if he caught me playing with dolls.  My mother says that if it had been up to her she would have banged on every door to let me become a girl, but my dad wouldn't stand for it."

Now 45, Anna Taylor from the UK transitioned at 11 and begin hormones at 13 after finding a doctor in Amsterdam willing to prescribe them.  Surgeons refused to perform her SRS until she was 18, she  had it 3 days late.

Anna ran away from home several times until, aged 8, she went to live with her grandparents who were prepared to bring her up as a girl.  At age 11, started at a new school where the headmaster was very sympathetic and agreed to let her register as a girl.  "For the first time no one was laughing at me. From being very withdrawn, I became very bubbly and outgoing.  The only allowance they made was that I had to change in a separate cubicle for games and use the teachers' toilets.  The school was afraid of another girl seeing something they shouldn't.  [But] I got very depressed when the other girls started wearing bras.  My own doctor wouldn't prescribe hormones for me at 13, so my grandmother took me to Amsterdam to find a doctor who would.  Within a few months I'd grown very small breasts.  Doctors agreed that I should have had gender reassignment surgery when I was younger but now that I was an adolescent, I would have to wait until I was 18."

Jasmijn age 9 (born as Colin).  During a summer vacation her family chose her new name.

A recent follow-up study of sex-reassignment in 22 adolescent transsexuals (ten started hormones under age 16, twelve under 18) found that post-operatively in all cases all signs of gender dysphoria had disappeared, they scored normally in psychological tests and they were socially functioning well.  Not a single girl/boy expressed feelings of regret concerning their decision to undergo sex reassignment.  The study concluded that with careful preliminary screening, starting sex reassignment procedures before adulthood results in favourable post-operative functioning.    

Puberty
Puberty can be defined as the biological developments which change boys and girls from physical immaturity to biological maturity.  For a transsexual child an inappropriate puberty sets a mountain that can never be full conquered, while an appropriate puberty offers a greatly eased path to a gender reassignment, both physically and psychologically.  

Laureen (formally James) Harries, age 27.  She transitioned when 19 and had SRS at 22.  She was a minor TV celebrity in the UK and is shown inset when 14.  Perhaps worryingly, her life story is atypical for a young transsexual.

Puberty is often a nightmare for 'gender dysphoria' children according to Cohen Kettenis, Professor of Psychology at the Medical Centre of the Free University in Amsterdam, "They develop an enormous dislike for their body."  Most children seen by Professor Cohen react with horror to the changes that occur in their bodies at puberty.  It appears that their so-called "transsexual" feelings become much stronger and they do not feel at home in the body that they now developing.  Margaret Griffiths of the Mermaids support group says very similar things, "Some girls and boys go through Hell at puberty, they have few friends, they are bad in the school, because they can concentrate on nothing, and some have suicidal thoughts."

When Riley (who had been living as a girl since age 7, after threatening to kill himself) was warned by her mother when age 10 that in a few years time nature would start turning you in to a man. her reaction was horrified "Please don't let that happen ... please!". 

Although the child may not admit to his transsexual desires at this stage, the parents will often start to have some concerns about their son.  The onset of puberty is a critical point as the child is faced with his own undesired physical masculinisation, often combined with a great jealously of girls and their physical changes, by age 15 some 90% are exhibiting feminine behaviour.  This is the point where many transsexual children finally admit to their wish to be a girl and they, or their parents, seek help. 

"Kelly" from the UK, at the start of her transition.

One now happily post-SRS girl described how she felt at puberty: "That was the hardest.  My own body was staging a mutiny, even."  At 16 she finally confessed to her secret to her parents who took her to several doctors but they wouldn't help, "I knew I couldn't be happy letting my body masculinize on and on.  And so at 17 I graduated from high school and found hormones on the street."

Now 21, Zoe concurs about puberty: "When puberty arrived I was repulsed by my erections and deepening voice.  At times I felt suicidal."  Jamie Cooper was 12 when she wrote her mother a letter saying that she should have been born a girl, they sought medical advice and were told that it could just be puberty, the feelings deepened but she had to wait until she was 16 before receiving hormone treatment - she transitioned on her 16th birthday.

How hormones affect a girls body during puberty (click graphic for large version)

A lot more information about puberty and its effects is given in the separate article here.
 
Hormones and Puberty
Body shape is controlled by oestrogen and testosterone.  During puberty, while boys are amassing bone and muscle thanks to their developed testes pumping out androgens (particularly testosterone), a high concentration of oestrogen in the female body results in the typical girl gaining nearly 35 pounds (15kg) of so called reproductive fat deposited on the hips and thighs rather than on the waist.  Another female hormone, progesterone, also plays a significant and complementary role, most particularly in the development of breast tissue. 
 

Professor Cohen's policy is that if it appears that the gender dysphoria feelings are becoming stronger then they should be prescribed puberty blockers to temporarily halt puberty until they are 16.  When they  are 16, and quite certain that they have the wrong body, they can be prescribed hormones as well as  to begin to change their outward appearance to more closely match their chosen sex.  "After that comes the actual sex-change operation".

Hormone Treatment for Young Transsexual Girls 
Ideally, in order to maximise the physical benefits, low level oestrogen treatment of the young transsexual boy-to-girl should begin at age 8-9 years.  Before the onset of male puberty (at about age 11, but can vary ±2 years) a bilateral orchidectomy (castration) should be performed to remove both testes and hormonal treatment then increased (additional oestrogen, later supplemented with progesterone) to initiate a female type puberty.  

When an orchidectomy is done before puberty, the results in terms of increased physical feminisation and decreased masculinisation are much more dramatic than when it is done after puberty.

Nina (formerly Guido) transitioned at age 11.  She's is pictured nearly 3 years later, age 13. (Netherlands)

Even if this pre-puberty ideal is not possible, the female hormonal treatment of the transsexual boy-to-girl can still have remarkable results if begun while the body is still at its most receptive age - the critical puberty years between about 11 and 17 (depending on the individual), but the earlier the better.  It is no coincidence that so many transsexual women who famed for their looks had begun taking hormones by 17 - Jenny Hiloudaki, Tula, Hari-su, Roberta Close, Dana International, etc. 

Doctors certainly seem to agree that giving - for example - a 13-year-old transsexual boy-to-girl doses of oestrogen will make her physically far more attractive as an adult women.  However they also agonise about the possible negative consequences - and perhaps their potential legal liabilities from prescribing female hormone to "boys".

A holiday snap from a 19 year MTF taking oestrogen and transitioning. (UK)

As a poor alternative to beginning full female hormone treatment in a young transsexual boy-to-girl, many medical specialists (who are often reluctant to start irreversibly feminizing hormonal treatment until the girl is at least age 16) instead prescribe a GnRH analogue such as Zoladex (Goserelin Acetate) or Lupron (Leuprolide Acetate) which prevents or dramatically reduces gonadal hormone production, including testosterone, thus preventing the onset of the masculinising changes of adolescence.  The drugs are normally administered with a nasal spray, or via a weekly or monthly subcutaneous injection into the abdomen.  While this treatment does nothing to promote female physical characteristics in the girl, it does at least prevent or greatly slow a male type puberty with its physical effects, and Dutch studies have recently confirmed the effectiveness of such treatment. 

Young transsexuals such as Kelly benefit enormously from blockers and early use of female hormones, but some fundamental physical aspects remain. (UK)

Unfortunately GnRH analogues are expensive drugs, but they are to be much preferred in adolescents over the cheaper anti-androgens such as Aldactone (Spironolactone) and Androcur (Cyproterone Acetate) which are commonly prescribed to post-puberty transsexual women.

Young transsexuals often struggle to understand the medical "best practice" guidelines that affect their life.  Riley (pictured right age 9) is now age 12 and will soon start to take both oestrogen and testosterone blockers.  It's been explained to her that this will make her body more feminine, her voice won't deepen and she'll develop breasts - but that she will be infertile.  Her reaction was "But I can adopt babies ... why can't the doctors take my testicles off now?"

A rare example of the medical community responding to the needs of young transsexual may have achieved in Germany when it was revealed in 2007 that doctors had prescribed puberty blocking and later female hormones to a 12 year old 'Kim', formerly Tim.  At age two, Tim was trying on his older sister's clothes, playing with Barbie dolls and saying "I'm a girl."  By age four Tim was refusing to get to his hair cut and wanted to cut of his "thing", for the sake of a normal life his parents increasingly accepted their son Tim as being their daughter Kim.

Kim age 13 and (right) age 16.  The benefit of early hormone treatment for male to female transsexuals is self evident. (Germany)

The situation reached a crisis when Kim grew increasingly distressed at becoming like other adult transsexuals with big hands and deep voices, whom she thought looked ridiculous when they dress like women.  Her father said "We saw Kim as a girl ... not as a problem. ... [she] reacted badly to the first signs of puberty... At that stage we realised that she was terrified of growing facial hair and her voice breaking".

Kim’s parents decided to help her get a sex change and consulted psychiatrists across Germany.  Some condemned their support of their child’s desire to undergo a sex change, or suggested that she be kept under observation in a closed psychiatric ward.  But Dr Bern Meyenburg, the head of a clinic for children and adolescents with identity disturbances at Frankfurt University, concluded that the child was serious. He wrote in his diagnosis: "Kim is a mentally well-developed child who appears happy and balanced. ‘There is no doubt of the determined wish, which was already detectable since early childhood. It would have been very wrong to let Kim grow up to be a man." 

A transgender group meeting at a university - in recent years "Transgendered" has finally been added to Gay, Lesbian & Bisexual.

Dr Meyenburg had once strongly opposed hormone treatment for children but changed his mind when one of his patients refused to listen and ordered hormones over the internet, then went abroad at 17 and had a sex change operation for a few thousand euros.  Dr Meyenburg admits that he was angry at the time, but said that today the woman is a law student and one of his happiest patients.  He now allows young patients to enter hormone treatment early, before puberty complicates a sex change. "They simply suffer less," he said, "it would have been a crime to let Kim grow up as a man".

Angel (formerly Oliver) Wheadon began taking her Mum's HRT pills at 9, transitioned at 12 (shown left at 13), was officially prescribed oestrogen hormones at 14, had  SRS at 17, and is shown right age 21. (UK)

Dr Achim Wuesthof, who is now treating Kim at a clinic in Hamburg, said: "Imagine a man who suddenly starts growing breasts or a woman who starts growing a beard against their will – that is how Kim and people like her experience puberty." 

Kim was thus prescribed female hormone therapy when just 12, and by age 14 was fully transitioned and living as a girl - with her identity and medical insurance cards changed to her new name and female sex.  She wanted to have sex-assignment surgery by age 16 but German law will only allow this when she reaches 18.
 

Effects of Early Hormonal Treatment
Early hormone use (i.e. during puberty) in a trans-girl allows a typically normal female body shape to develop, with significantly more fat and less muscle than otherwise, the girls post-puberty body shape and "figure" will become far closer to female than male norms in its proportions.  In general, increased levels in the blood plasma of oestrogen and progesterone will stimulate and promote the growth of female secondary sexual characteristics (breasts, fat distribution, pubic hair pattern, ...) while the reduction in the levels of androgens such as testosterone will, if early enough, completely prevent the development of male ones (deepening of voice, facial hair, muscular development, ...).

Female hormonal treatment has a dramatically greater effect if begun before a male puberty has started (on average age 12, but plus or minus 2 years) than after after a male puberty has completed (on average 17, plus or minus).  This is a severe problem given the great reluctance to doctors to assist transsexual patients under age 18.  Incidentally, the anticipated and achievable benefits from starting female hormones decline rapidly in the decade after puberty ends. 

Maximum possible feminsation occurs if hormonal treatment begins just before a male puberty would have start started.  Very conveniently, girls tend to start puberty two years earlier then their male peers, so high dose hormone therapy intended to initiate a full female type can be safely started by age 11, although it in practice it is often deferred to 12 or even later, particularly if the individuals physical development allows that.  If her testes were removed in infancy or childhood, then for health reasons low level hormone therapy should be begun by age 9 - an age at which many girls begin to notice some initial puberty changes, in particular the development of breast buds. 

As indicated already, surgeons have become very reluctant in recent years to perform a bilateral orchidectomy (castration) on even young intersex'ed patients, let alone gender dysphoric boys, however failure to do so does accept the slight risk that even suppressed testes might still produce enough androgens for a very sensitive body to react to them.  The nightmare scenario is a confused body going through a double male and female puberty - the girls hips broaden and her breasts swell under the influence of oestrogen therapy, but simultaneously her voice deepens and facial hair appears due to the testosterone being produced by her testes.

After legal debate Johanna (formally Johannes) Bulow (Germany) was allowed puberty blocking drugs at age 12 and female hormones at 13.  She's shown age 14, and (inset) age 15 holding her new identity papers.

There seems to be no consensus amongst clinicians as to whether pubertal development is more 'natural' in XY girls with oestrogen producing ovaries, than in XY girls (more commonly intersexed rather than transsexual) taking hormone replacement therapy (HRT) following early orchidectomy.  This lack of consensus can actually be considered a good indication of the great  effectiveness of early hormone therapy.

The reduction in levels of "male" androgen hormones caused by oestrogen treatment will also have some slight affect on the skeleton - reducing male type rugged'isation and enhancing female type features, for example slightly broadening the pelvis and helping reduce the girls adult height (by perhaps an inch or two) compared with if she had experienced a male puberty.  However, while hormones play an important role in post-pubertal body shape, it's thought that the male "Y" chromosome is mainly responsible for skeletal growth.  As a trans-girl is genetically "XY" she will thus still experience some a degree of skeletal masculinisation, even if she commences female hormone treatment at 11 or 12.  In general, her physical characteristics as determined by her skeleton (height, skull, hand & feet size) will lie between the male and female norms post-puberty - although more towards the former than the later.  This not necessarily bad as the western idea of feminine beauty is for tall and leggy women.  As an adult, the woman will typically be both tall compared to the average woman (67½" vs. 64¼") and have long legs - both absolutely (32½" vs. 30") and relative for her height, ideal for those girls with ambitions as a model!  [For more information about average male and female body sizes, see the article on this site]

"Lucy Parker is a typical teenage girl, obsessed with clothes, boys, make up and shopping.  But ..."  A BBC documentary followed Lucy (formerly Richard) - who transitioned at 16 - as she waited for a breast augmentation days after her 18th birthday. (UK)

In a genetic girl, her increasing production of oestrogen during puberty causes her skeleton to mature so that growth eventually stops.  Oestrogen treatment can speed up this bone maturation by accelerating the completion of growth in the growth plates (the zones of growing cartilage near the ends of children’s bones) and thus suppresses growth somewhat, by up to two inches.  Pediatric endocrinologist sometimes prescribe large doses of oestrogen (usually Ethinyl Estradiol) for a period of several years to deliberately restrict growth in excessively tall girls, and the same technique can be used to help induce in young transsexuals a final height in the typical female range of 61 - 67".  However, obtaining supervised treatment for a transsexual boy-to-girl is difficult, arguing that height is not a disease, endocrinologists are becoming increasingly reluctant to treat even a genetically female "XX" adolescent unless bone growth X-rays show that excessive adult height for a female (over 71") appears likely. 

Model and actress Pascale Ourbih (Algeria) transitioned when she moved to Paris, age 18, and had surgery soon afterwards.

Overall, the physical results of early hormonal treatment should be extremely successful, the girl developing a well feminised physique with full breasts (although rarely as large as the girl would like), no beard, plentiful scalp hair, and an unbroken female type voice.   It's difficult to over-exaggerate just how great these advantages are, and how much of a disaster each year of delay is for the transsexual girl whose skeleton and body is rapidly turning in to that of a man.  The end of puberty is a fundamental and irreversible physical marker, from which the plausible effects of feminizing hormonal treatments on the body of a transgirl/woman decline with depressingly rapid speed.  For any transsexual woman starting treatment when already physically mature (and this merely means age 20 onwards), a muscular and robust stature; a deep and masculine sounding voice; obvious facial beard growth; and a receding hairline, are just four of the immediate challenges that may seriously threaten her ability to pass convincingly as a woman.  She also faces the high cost of electrolysis, breast augmentation, facial feminisation, ... etc.

Hormone Regimen's in Transsexual Girls
There seems to have been little published research with regard to the dosage for hormones in young transsexual patients, however research which relates primarily to Androgen Insensitivity Syndrome (AIS) patients is also probably applicable to transsexual girls.  Zachmann et al cite one AIS patient who had undergone orchidectomy in whom oestrogen administration was started at the earliest estimated pubertal age of 10.3 years in the form of Premarin 0.625 mg three times weekly.  It was found, however, that this stopped growth of the girl prematurely and the authors felt that it would have been better to have given the patient 0.005 - 0.01 mg ethinyloestradiol daily, instead.  From studies of patients with Turner syndrome it has been suggested that to ensure normal pubertal growth, physiologic oestrogen replacement should be started at the appropriate bone age of about 11 years and should not be delayed in the hope of achieving a greater mature height.  Batch et al suggest a regime of 5 micrograms of ethinyloestradiol daily for the first 6 months, increasing to 20 micrograms daily by the end of puberty.

Katie (USA), shown age 16 and while still in High School.  She transitioned when age 10 and her parents fought for her right to attend school as a girl.  Although on female hormones for many years, she was still waiting for her SRS in early 2003, now 19.

Soule et al. suggest that the best course of action may be to perform a orchidectomy just before puberty (at 11 years in a case quoted) followed by oestrogen therapy (ethinyloestradiol 2 micrograms daily, gradually increasing to 20 micrograms over 2 years, in the case quoted) with regular bone density measurements. This policy, it is suggested, reduces any slight risk of malignant transformation of the gonads and ensures adequate oestrogen activity throughout the critical years of bone accretion. 

However, oestrogen levels are higher in XX girls than in XY boys, even in childhood.  XX girls start producing oestrogen at 8 or 9 (i.e. a year or two before breast development) so several clinicians therefore recommend early  oestrogen supplements in XY girls, irrespective of whether or not the gonads are in place.  Dr. Stanhope suggests 1 microgram ethinyloestradiol per day from age 8-9, with an increase at about 11-12 years.
 

Early hormone treatment is not a miracle, but the benefits such as female hair pattern, no beard growth, no Adams Apple, no broken (deep) voice, breast development are immense.

Females Hormones and Attractiveness
A very awkward problem for psychologists advocating delayed hormonal treatment for young transgirls is that as result they will be physically less attractive as a woman to men.

There is a strong and direct correlation between the level of a girls oestrogen levels during puberty and how attractive and feminine she is perceived as a woman.  For example the hormone has lasting effects on bone growth and tissue formation as well as the skin’s appearance during the average seven-year-long puberty.  Miriam Law Smith of the University of St Andrews states the hormone has a hormone has a crucial role in determining facial appearance, giving 13-year-olds doses of oestrogen will "certainly may make them more attractive [to men]" although she adds "who knows what other effects the hormone may have?" As regards the last comment, pubertal girls who have been prescribed oestrogen to prevent excessive height (over 6 feet) may according to one study subsequently suffer from lower fertility.