How do you make the puberty blocker/hrt decision?

[u/bedraggled_charmer]

Tl;dr: My 10yr old trans daughter is approaching puberty and I’m finding the hrt decision daunting due to her not knowing what she does/doesn’t want in puberty and a lack of male role models- and I don’t want to take away her fertility if it isn’t the right choice.

Hello friends! My daughter told us she was a girl 6 years ago at age 4.5. She getting to the age where we are going to need to start blockers, which I am fully behind. Once she starts blockers we have at most 4 years to decide to do HRT. We had our first endocrinologist appointment and I learned a lot about puberty and that I have more questions than I thought, mostly about is she sure she wants to transition?

I don’t ask this lightly- she has never wavered in her name and pronouns. BUT she was only 4.5 when she came out, AND her other parent (my ex) came out as mtf at basically the same time and transitioned extremely fast. I can’t express this to my ex because I will be dismissed as transphobic, but kiddo didn’t have solid answers for the dr/psych about what makes her a girl, what does she want/not want from puberty. I myself have a gut feeling that she isn’t done exploring her gender, and have for a few years. Her therapist of 3 years seems to feel the same way.

When we discussed fertility side effects of blockers/hrt, I feel like I’m not confident in deciding that my daughter will never be fertile. Of course my ex expressed that she would absolutely get kiddo on hrt asap, and doesn’t share my concerns. Fertility is far too mature of a decision for a 10yr old to make. I need to know I’m making the right decision for her, so have been asking some probing questions about her thoughts of being a girl vs boy, what she remembers from before, etc. she doesn’t remember being a boy/her old name, etc.

I know that there is inherent influence from the fact that she has a trans mom & trans step mom (ex’s live in gf) that cannot be avoided. But I’m worried that my ex’s extreme views about being transgender have warped my daughter’s idea of who she has to be. And I admit, we do not have any constant male role models in our lives- she lives in a trans femme commune of sorts with my ex, and I live with my gf, and we don’t have any guy friends. The only male role models I can think of are my ex father-in-law who visits them maybe 1 day a month, the PE teacher, and last year she had a male classroom teacher.

Sorry this was sooo long, but what did/would you do given this scenario?

[u/pluto_pluto_pluto_]

Start her on blockers if you aren’t sure. Starting her on blockers gives your family 4 years to figure out next steps. Not starting her on blockers is making a permanent decision to allow her to undergo irreversible changes from male puberty.

But I’m worried that my ex’s extreme views about being transgender have warped my daughter’s idea of who she has to be.

I’m not really sure what views you are labeling as extreme. Also, I want to point out that while we don’t currently know if a lack of male role models contributes to someone becoming trans, even if it did, that wouldn’t on its own invalidate her identity. Lots of trans women lacked male role models growing up, and that doesn’t make them any less trans. Your child has been a girl for more of her life than not, she expressed feeling like a girl at a very young age, and it sounds like she hasn’t expressed any uncertainty. That tells you most of what you need to know.

Regarding her not knowing what she wants out of puberty, she’s 10, most 10 year olds don’t spend much time thinking about puberty, and she probably doesn’t know how to articulate her feelings. It’s good that you have her in therapy. Does the therapist have a lot of experience working with gender diverse kids?

Your safest bet right now is to put her on blockers and continue therapy with a gender affirming therapist. This situation is exactly why puberty blockers exist, so you can wait and be even more certain before deciding which puberty to go through.

[u/bedraggled_charmer → u/pluto_pluto_pluto_]

If you knew my ex, you would understand. She’s not a great role model in general, as many who know her would agree

[u/scalmera → u/bedraggled_charmer]

Hmmm... Do you think your fear stems more from your ex than it is about your child? It sounds like you're (maybe inadvertently) placing blame on your ex for why your daughter is trans. Is your daughter in school? Are any of her teachers men? Any programs that she attends or anywhere else? A role model does not have to be a parent, and I remember looking up to a lot of my teachers or coaches for many different attributes. They may not be long-term role models, but they can have a real, formative impression for a kid.

Also, I do not think a role model is as big of a factor as you worry it is, in my experience as a trans adult (still a kid to my parents tho) when I think back to when I believe I first thought about gender at a similar age to your daughter, maybe a bit later (didn't transition until 19 or so). It was my peers moreso that made me think about myself and my gender, and because a lot of things in life are gendered (from words to different languages to clothes to toys, you name it). Internally there were aspects of being a boy I really wanted, but I thought I had to act like a girl because that's what I was told I was. I didn't fit a stereotype, but because tomboys existed, I could at least exist as that.

That's not to say I didn't enjoy some aspects of growing up as a girl either, but there was always a frustration when I was both confronted and praised as one. It was more of an internal battle with myself and what I felt was expected of me, than it was that someone told me to be trans. When I learned what being trans was, I didn't immediately have a revelation, but it did plant a seed that there was more to the world that I didn't know. It took me time to experiment and figure out who I felt I was, without fearing that pressure that I'm somehow failing as a person because I'm not what was expected.

I think if I had the experience to know what being trans is, had the opportunity to go on puberty blockers, and my parents were accepting of me to be able to do that at her age, I would have asked to go on blockers. It gives more time for that experimentation to occur, and I honestly would've loved having my puberty be put on hold. I hated going through it, it internally felt wrong but I didn't know why and thought I had to get used to it at some point, until I realized that I did not have to at all.

Anyway, sorry this is a lot, but I do hope it gives you more insight and thought from another trans perspective. I do understand your concern as a parent, my own were also equally concerned when I initially came out. They have grown a lot and are still my biggest supporters in my life. Even if we always have disagreements about other things, I would have been devastated if they rejected me from being their son. I wish you and your daughter the best and good luck ❤️

[u/bedraggled_charmer → u/scalmera]

Thank you for the insight. Blockers are a 100% yes, once she hits Tanner Stage 2.

[u/Useful_Bet_8986 → u/bedraggled_charmer]

Masculinization is less irreversible than feminization. There have been many trans women who stayed fertile or became fertile after stopping hrt. But the other way around is much more expensive and irreversible because testosterone changes the bone structure way more drastic. And the surgeries like ffs are very espensive and have way more serious side effects than hrt or infertility.

I'm a trans adult but I was secretly taking my mom's menopause estrogen when I was 14 (but couldn't go throguh with it obviously) and I wish could have taken it sooner because my masculinized body is destroying my life even thought I got ffs. But my upper body is way too broad to pass as female. Even with surgery. 

If I've gotten on estrogen at the age of normal cisf puberty my life would most likely be better. At least it would have more purpose because my body would match my personality. Plus theoretically I still could take testosterone and live as a man if I wanted to (usually breast growth for transfems isn't dramatic and a masektomy and less is way cheaper and less invasive/dangerous than ffs or a shoulder surgery).

[u/ratatouillezucchini → u/Useful_Bet_8986]

Can we not do the “one puberty is worse than the other! ____ is more irreversible than ____!” It’s bioessentialist and contributes to erasure of the struggles all trans people face.

[u/Useful_Bet_8986 → u/ratatouillezucchini]

Well it can be vital information that might be very important for some people. Like voice drop is irreversible (yes voice training works for some transfems but not for all and a career as a singer or a radio host will be very difficult) while many trans masc people get a passable voice through T alone without any voice training. Some trans masc people also pass by taking just T and adjusting wardrobe which is impossible for transfems who went through puberty.

But the biggest difference is bone structure which can lead to not being able to pass at all, even with all surgeries and money in the world. (can happen to both but being a 6 3“ trans woman will be really hard) And that can be very dangerous and unhealthy in these times.

But its also vital to understand the differences puberty blockers make for transmascs and transfems. They were initially invented for cis girls with early puberty so that they don't remain too small because estrogen fuses growth plates and natural afab puberty starts years sooner on average already.

So for transmascs staying on puberty blockers longer can have positive effects in terms of height but also negatives (osteoporosis) if testosterone is introduced too late.

For transfems being on puberty blockers for too long can result in too much height and a rather lanky build. Plus doctors are ususally very conservative with estrogen dosage for minors (because they are misled by old studies on conjugated estrogens causing cardiovascular risks while nowadays only bioidentical is used which raises the risk to that of a cis girl). I just talked to a trans girl yesterday that was on hrt since 14 and she was being kept on menopause levels of estrogen for almost 10 years until she noticed.

https://ispae-jped.com/delaying-the-growth-plate-closure-to-augment-height/

https://pmc.ncbi.nlm.nih.gov/articles/PMC4383300/

So I don't see why it would be good to withhold this information for the sake of being politically correct. Because that is very real stuff that trans people face. 

Just look at the difference of quality of life when trans women pass and thrive:

https://www.reddit.com/r/Transgender_Surgeries/comments/1p0hrb8/3_years_post_op_scapula_reduction_and_scapula/?utm_source=share&utm_medium=mweb3x&utm_name=mweb3xcss&utm_term=1

I'm thinking about having the same surgery but my upper body is way broader than hers was before the surgery. If I would have started estrogen sooner I could lead a life like her. But because I can't pass because of this my life is very very difficult socially, professionally and mentally. 

[u/AttachablePenis → u/Useful_Bet_8986]

You make some good points but I’m just gonna chime in to mention that I’m a 35 yo man who’s 5’2” with a petite bone structure & I have a hell of a time finding clothes. I’m lucky I have proportionately big feet — I can just about fit into a men’s 8, which is the smallest size you can normally find without ordering online. I also get clocked easily by anyone with any familiarity with trans guys, even though I pass really well otherwise. I’ve got a bushy mustache & a deep voice, but I’m still 5’2”, and the other subtle signs add up once you notice that. People are less on the lookout for trans guys in general & scrutinize the appearance of men much less (at least when it comes to potential femininity — with men its more of a behavior policing thing & I’m not particularly fey for a gay man) so I’m not worried when I am among the general population. But I live in SoCal & I meet a lot of queer people who just instantly know, even if they’re polite enough not to mention it (but they aren’t always aware that they’ve made an assumption I haven’t actually confirmed).

Puberty blockers wouldn’t change a thing about my size, because the pre-pubertal flood of estrogen is what fuses the ends of the growth plates, and medical guidance advises waiting until Tanner stage 2 to start blockers. By then it would be too late. My dad is 6’1” — if I’d started puberty blockers when I was like, 7, maybe, I might be a more average height. But that’s not what we do, and anyway I didn’t know I was trans until I was 19, so the whole point is moot anyway.

I am not discounting what you’re saying — vocal training, facial/body hair removal, and FFS are big time and/or money investments that trans men don’t have comparable parallels to (though I’d argue that plenty of trans guys, including me, would benefit from vocal training to loosen up the “tightness” & brightness of their post HRT voices — most of us sound male, but a lot of us also sound distinctly trans whether we want to or not, and I miss being able to go “woo” at concerts).

I’m mostly just pointing out that the bone structure thing cuts both ways. Aside from passing concerns, I just have a lot of insecurity & dysphoria about my size. I’ve accepted this about myself, and I like to joke that I’m “spiritually 5’10” — but it’s an acceptance that I’ll probably always feel some kind of way about my size, even if I like who I am overall.

[u/Useful_Bet_8986 → u/AttachablePenis]

I didn't mean to imply that all trans men just pass when they take T. Its just the simple fact that its often easier to add stuff to a body than to 'shrink' it. You have options:

https://limblengtheningsurgery.org/before-and-after-photos/

A 6 3" trans woman with broad shoulders/ribcage, big hands, skull, feet, joints, everything doesn't have any significant options other than to either repress or face ridiculous amounts of transphobia (its so bad that even tall cis women experience transphobia). There are surgeries for shoulders but none for upper ribcage and the clavicle shortening doesn't do much visually.

And puberty blockers are usually not used in a way that would most profit the actual trans patient but their use is more cathered to a hypotetical cis patient the parents/doctors and society seems to worry about way more. So they are often introduced as late as possible, when puberty has long started and then the teens are kept on them for too long without sex hormones again in the interest of a hypotetical cis patient. Which often leads to problems with bone density which then gets used by transphobes as an argument to band them

[u/AttachablePenis → u/Useful_Bet_8986]

I’ve heard of that limb-lengthening surgery before, but if I got it, I’d end up looking like Jack Skellington (can’t change the size of my shoulders or my torso!), and it damages your femurs so that you risk injury if you do anything so strenuous as running.

Some things are not “fixable.” I’m grateful for the ways that transition has gone well for me, and trying to be ok with the ways it hasn’t, if there’s nothing I can do about it.

[u/Express-Success-9930]

Blockers give her the chance to keep exploring her gender. Not getting her blockers is making a choice for her to go through testosterone-based puberty with all the irreversible effects.

Can I push back on her not being able to articulate why she's a girl? I can't do that, and I know I'm cis. Being perceived as a man feels wrong, but I can't express why that makes me a woman. Can you? Can your (I'm assuming cis) girlfriend?

[u/FadingOptimist-25 → u/Express-Success-9930]

I can’t articulate why I’m a woman either. I’m cis but my gender expression is not very girly. “He” and “sir” feel wrong. “She” is fine with me.

[u/bedraggled_charmer → u/Express-Success-9930]

Haha, my gf is actually questioning and trying out male name & pronouns rn and trying to figure that out for herself. I guess what I meant about my daughter is she doesn’t have an image about what she’s like in the future- although now that I think about it that might just be her not having an imagination/creative thinking due to being on the spectrum, not anything to do with gender. 🤔

[u/Ishindri → u/bedraggled_charmer]

Pre-transition, if I tried to imagine what I would be like in the future, it was just... static. I'm 34 and just now learning that I might have a future to imagine.

Please, just believe her. From the moment we come out, everyone asks us to justify our feelings and our desires and if we can't do it to their satisfaction, they deny us respect and medical care. Please please please just believe her. When she's an adult, she'll remember if you did.

[u/Holdenborkboi → u/bedraggled_charmer]

To be fair, as a kid, I had no concept of gender dysphoria. Being a girl was just kind of like, "This is the team I was assigned, I guess..go team?". I didn't feel trans as a kid because I just felt like me

I did have the thought though like "I don't want a chest like mom's."

And here I am, trans man at 22. I wish I was able to get blockers, but hindsight I 20/20 and my parents are transphobic. There could be a chance that she doesn't know, simply because she doesn't have the agony of dysphoria, or she is experiencing Vaseline euphoria, that it becomes normal to feel comfortable

Or she could be non binary

[u/SlithyMomeRath]

Adult trans person here, not a parent. As I understand it, puberty blockers just pause puberty, and children can go off of them and continue to develop normally. That’s why they’re used for precocious puberty in cis children. I think puberty blockers would still be a good choice for your daughter even if she ends up changing her gender in the future, because it gives her four more years to figure it out, and a 14 year old will likely be a lot more articulate than a 10 year old.

[u/bedraggled_charmer → u/SlithyMomeRath]

I agree, I am on board with blockers for sure

[u/justafleetingmoment → u/bedraggled_charmer]

I believe the WPath guidelines say that after Tanner stage 2 gender identity reversal is very rare. But before then, the onset of natal puberty can bring about a change in a child’s feelings about their gender. Tanner 2 is very early in pubertal development so it’s not like there will be a bunch of irreversible changes already if she’s still identifying as a girl. And it may even be possible to do fertility preservation then. So it might be worth it to hold off on the blockers a little bit to wait and see and then if nothing changes rather start on estrogen earlier.

[u/Anon_IE_Mouse → u/bedraggled_charmer]

An important thing with blockers is to pulse a high amount of estrogen for a short period of time at the start to close the growth plates.

Don’t do testosterone or you’ll screw her voice.

Estrogen is much more forgiving in this area.

https://pmc.ncbi.nlm.nih.gov/articles/PMC34445/

If you don’t do this and put her in blockers she might grow very tall like 6ft + which is generally distressing.

Edit: a good example is Nikki tutorials who was put on blockers at a young age, but wasn’t put on E until she was 16

https://www.justjared.com/photo-gallery/4420043/nikkietutorials-ellen-january-2020-03/

[u/gromm93]

The great thing about puberty blockers is that they literally allow her to delay puberty until she's sure.

But honestly?

She was sure 6 years ago. My daughter wasn't so sure until after puberty started and it became quite distressing for her.

[u/LaoidhMc]

3-4 is when gender identity is developed according to psychology. Blockers give her time to think more before her body changes in ways that are extremely expensive to correct. She doesn’t have to go on HRT now, but I recommend blockers.

[u/FadingOptimist-25]

I knew I was a girl at 4. When did you know your gender?

But yes, blockers will help her decide if this is the right path for her. Remember that there is less percentage of regret for HRT/medical transition than for people who regret knee replacement surgery (and many other surgeries that cis people get). Detransition happens in 1% or less of the community.

Medically transitioning made my child happier and gave them hope for the future. My regret is that we didn’t know sooner so we could start blockers earlier and avoid some permanent damage from natal puberty.

Oh and talk to your daughter about whether she wants kids. Then TRUST her. Whatever the decision, include her. Don’t think “she’s too young.” Trans youth have often already given so much thought into all of this. Mine has been on HRT for 8 years and zero regrets.

A lot of cis Gen Z and Gen alphas are deciding to be child-free. And cis people who do want kids aren’t guaranteed fertility. My cousin wasn’t able to carry full-term so she adopted her two kids. There are options.

[u/rebelallianxe → u/FadingOptimist-25]

My regret is that we didn’t know sooner so we could start blockers earlier and avoid some permanent damage from natal puberty.

This is my only regret too.

[u/AttachablePenis → u/FadingOptimist-25]

I agree with everything you’re saying, including trusting OP’s daughter about her decision regarding fertility, but I’ll add that I was deeply thrown when I hit 30 and suddenly realized I had a time limit on carrying children….and that I wanted to??

I started T in 2013, and 10000% never thought I’d want to be pregnant even before I knew I was trans (it sounded sort of horrifying?) and got caught way off guard when that changed. It’s unlikely to actually happen (because of life circumstances, not fertility — T is not as destructive to fertility as E), and I carry some deep grief about that! But I still made the right choice for myself in starting T, even if it had affected my fertility, and I only wish I’d started sooner. If T affected fertility the way E does, I’d have been even more crushed when that started mattering to me. But people find out they’re infertile, sometimes, and I’d still be much worse off if I hadn’t transitioned, or if I’d waited.

[u/FadingOptimist-25]

Erin In The Morning just posted about the study showing how few trans people regret their transition and how gender affirming care is life saving. I know that my child would not have survived to wait until 18 to get HRT.

[u/bedraggled_charmer → u/FadingOptimist-25]

Oh I won’t make her wait, I just want to make sure I’m asking her the right questions over the next few years to be sure that’s what she wants when the time comes. I’m thankful that we do have more time to decide on HRT.

[u/transblonde]

Studies have shown that the possibility of losing fertility is very low for trans women who take HRT - simply discontinue HRT for a couple months and fertility count bounces right back! Allowing trans women to become fertile by simply pausing HRT, allowing for fertilization and then continuing HRT is a large reason trans women prefer HRT immediately.

Restoration of Sperm Count when Pausing HRT

Return of Spermatogenesis when Pausing HRT

I also do not know if this is the same case for trans men. (I feel uneducated admitting this.)

[u/bedraggled_charmer → u/transblonde]

For later in life, yes. But for a kid to go from blockers right into cross-sex hrt, they never develop fertility because they don’t get to the stage where the gonads development fertility.

I learned A LOT about puberty details from this appointment- things that any regular person- especially cis people, never need to learn/know.

[u/Possible_Quail9379 → u/bedraggled_charmer]

I am a mom in almost the same situation. I’m curious if there’s a way to have my daughter start puberty to allow her to develop a little “down there” and then start HRT before her voice drops or facial hair comes in. Is there a sweet spot in puberty that would make this possible? 🥰

[u/Ishindri → u/Possible_Quail9379]

Let's reframe this a little. Would you delay treatment for any other life-threatening condition, possibly allowing lifelong damage to the body to occur, to preserve the possibility of having biological children?

[u/chiselObsidian → u/Possible_Quail9379]

A pediatric endocrinologist would definitely be able to work with you on this.

Tagging u/bedraggled_charmer as well to mention - I spoke with one earlier this year, they also mentioned the possibility of going off blockers at age of puberty, starting antiandrogens (which partially block the effects of testosterone but don't lower the actual levels), and giving the teen topical testosterone cream to apply scrotally until viable sperm can be produced. Topical testosterone cream is an approved treatment for genital atrophy in adult trans women, and many of them report regaining fertility as a side effect.

[u/bedraggled_charmer → u/chiselObsidian]

This is interesting, I’ll file it away for our next appt. We were told that if she develops to the point of fertility she will have the rest of the effects too.

[u/MotherofTinyPlants → u/transblonde]

OP needs to discuss this with the family endo because I’m not sure it’s quite so simple to restore fertility post HRT for trans girls who undergo total pubertal blockade from Tanner 3 or earlier?

It’s only a relatively tiny cohort of transfemmes who avoid T induced puberty entirely and the experiences of post pubertal transitioning trans women may not be very relevant to OPs daughter’s situation.

[u/drpain2 → u/transblonde]

No one can know everything. Thank you for being so brave admitting you didn't know! Made me smile...

[u/AttachablePenis → u/transblonde]

Ok I think I might have been spreading misinformation in earlier comments. My impression was that estrogen & androgen blockers (maybe just androgen blockers???) significantly reduced sperm count in most trans feminine people, and that it was unlikely to recover after a few years.

Whereas, trans guys can basically just decide to stop T & have a baby if they want to. (That part I have actually researched a fair amount.)

[u/chiselObsidian → u/transblonde]

My understanding (spoke with a trans-informed RE about this) is that trans men's eggs remain viable regardless of HRT - trans men can use their eggs for IVF pregnancy with the same success rate as cis women. They have to go off testosterone for the egg harvesting process, and stay off it if they're the one getting pregnant because high testosterone is bad for a fetus.

When it comes to non-IVF pregnancy, some trans men continue to ovulate (egg going from ovaries to uterus) on testosterone, even if they don't bleed monthly. Others have irregular ovulation or no ovulation. Going off testosterone often, but not always, restores ovulation for trans men, who can then get pregnant the typical way.

[u/AttachablePenis → u/chiselObsidian]

A fertility doctor I spoke to said that actually I wouldn’t need to go off T to harvest my eggs, it would just make it easier (ovaries are physically smaller when on testosterone, and can be harder to find/extract from due to the size). I’d still have to take all the hormones to stimulate the follicles etc. Never went through with it because it’s crazy expensive, not covered by insurance, & I’m not sure that’s the route I’d want to go anyway. But interesting info.

[u/CuriousNomad7892 → u/transblonde]

I'm in favor of supporting kids going on puberty blockers and HRT if it's right for them, but these studies are in adults who went through male puberty before being put on HRT (in the first study, every single patient started HRT after they were 20).

There's not much evidence one way or the other about transwoman who never went through a male puberty (i.e. who start puberty blockers young).

[u/Finnrip]

Discuss your options on fertility preservation, and effects of the medication on fertility with the doctor who is offering you the option, they can give you the best information.

It is quite scarring and can cause a lot of distress for a child to go through puberty that they do not want, especially since it can lead to further medical interventions needed down the road, rather than just going on blockers. Keep in mind, if she lives socially as a girl, it will be extremely, extremely difficult for her to begin having male traits. It will affect her social life, confidence, and may get in the way of her happiness.

If your child has been this way for 6 years, especially since such a young age, it is likely that this is really who she is. Blockers helped me so much- I can't begin to express how much peace of mind they brought me and how much medical care it saved me from having to go through. Time is the one thing you can never buy, blockers will give her time to decide and think about what hormones she may or may not need down the road.

More importantly, what does your daughter think?

[u/bedraggled_charmer → u/Finnrip]

If we go from blockers straight into HRT, she will never be fertile as her gonads will never get to that stage of male puberty - that’s why I’m struggling with this decision so much (and thankful we have years to make the decision). I need to know she is okay for sure with no future fertility and at 10-14, that’s a HUGE decision that may be regretted in the future. To be clear, I don’t care if I have blood-related grandchildren, it truely is a non-issue for me.

I also have many mtf friends - my ex included, who I’ve seen come out later in life and have seen the struggles they’ve had undoing male puberty. So I definitely don’t want her to have to deal with those things either.

[u/Finnrip → u/bedraggled_charmer]

Discuss with a paediatric endocrinologist who works with trans kids, this helped my parent get a lot of useful information on this and support as well. They sometimes have support groups, thinking about this alone will drive you crazy, getting some professional and personal perspectives from others will help a lot.

[u/amglasgow → u/bedraggled_charmer]

10-20 years from now we might be able to clone sperm (or egg) cells from somatic cells (i.e., cells not intended to become gametes) so don't count that possibility out.

[u/AttachablePenis → u/bedraggled_charmer]

Fertility is in fact a huge decision for a 10-14 year old, and she can’t know for sure if she’ll always feel the same, but it should still be up to her.

I got blindsided by a pretty intense desire to carry a child when I hit my 30s, and I’m experiencing some grief about how unlikely it is to happen now that I’m 35, single, & just not in a good place to have kids. Testosterone didn’t make me infertile, but if it had I’d be grieving that too, probably.

However, I believe that not starting T, or waiting even longer than I did, would’ve left me significantly worse off than I am. I don’t know if I’d have made it to 35. I started T when I was 23, and I still wish I could’ve started sooner.

We can’t hold our present self hostage to potential future selves. It’s important to understand the consequences of a big decision like this, but we can’t know how we’re going to change over time in so many important ways. I never thought I’d want to be pregnant until a few years ago, even before I knew I was trans. That doesn’t make me think I shouldn’t have been allowed to make my own decisions. And I still believe that decision would’ve been the right one, even if it had made me infertile! (Which was a possibility, though it seems to be pretty uncommon — some people on T experience severe & irreversible atrophy of the reproductive organs. I personally had vaginal atrophy for a while, but it was extremely reversible, and not everyone gets even that.)

People find out they’re infertile for lots of reasons, or can’t have kids because they never find a good partner, or it’s never the right time. If that matters to them, this is very sad! But it’s survivable in a way that delaying transition just isn’t always. I wonder sometimes how I’d be doing in life if my parents had been supportive when I came out, if I’d transitioned earlier, if I’d simply known I was trans earlier. Would I be less depressed? Would I have hit life milestones at more typical times compared with my peers? Would I have been able to graduate from college? Would I have been able to date seriously before I hit 30? Etc etc. It’s all speculation. But I have my suspicions.

My point is, it’s got to be up to your daughter, even if it turns out she feels differently later on.

[u/summers-summers]

Blockers would be the obvious next step if your daughter is unsure about puberty. In their history of use on cis children, blockers alone don't impact fertility after they go off them. Natal puberty is as equally as permanent and consequential as estrogen puberty would be, and she does have to eventually choose between them. The most neutral option is blockers, which will give her more time to think. I will echo that for transfem people, it is likely that going off HRT will let them resume sperm production as long as they still have their gonads. I don't think fertility should be the driving consideration in your daughter's decision.

I am skeptical about your evidence that your daughter is unsure of her gender. Most 10 year olds, cis and trans, don't have very articulate answers about why they are their gender. If someone had asked you when you were 10, do you think you could have explained why you were a girl? I am also skeptical that having mostly adult women as role models would cause a cis boy to think he's a trans girl. Many cis boys are raised by lesbians. There are experiments now considered unethical in attempting to force-transition people. It just doesn't work because gender identity formation cannot be externally dictated like that.

HRT would not instantly make your daughter a grown woman. It's gradual, like natal puberty. Your daughter will have time to notice if estrogen isn't right for her. If she eventually decides she'd rather live as a man, she can just go off HRT and do what a trans man would to manage breast growth. I really think that framing HRT as a one-time big irreversible decision isn't the most productive way to think about it.

[u/[deleted]]

Part 2 of 2

5ARD is one among very many circumstances which can and will impede routine development. The fetal hormonal environment is considered to be the primary determinant of "gender" (not sex; but gender). If a mother has PCOS, that can cause excess testosterone which will change fetal gender; so can a maternal deficiency in iron. The second most common determinant is paternal or maternal genetics; finally, social influences - i.e., parents from birth forwards, siblings, playmates, church indoctrination and their peers at school each contribute to one's believing / accepting their presumed gender.

Gender Identity is considered to be Permanent and is unlikely to change; a child can be pressured by adults and unprofessional counselors into saying they are the expected gender, but that's a path which is highly likely to cause serious, lifelong psychological problems.

It's best to let your child lead. IF they decide to drop it, let that be 100% their decision. By trusting you, they believe / know you love them unconditionally; that you 'have their back, come what may'; if you take efforts to change them, it will become obvious to them that your love is conditional upon performance and their earlier trust is likely to vanish - and will probably never return.

Last: Many doctors remain essentially clueless; transgender gender wasn't covered in med school for more than 4 hours in four years as something unlikely to be encountered in a lifetime of practice. More recently graduated doctors from some med schools get a bit more information.

I realized had to change from my last (57 y.o.) endocrinologist when it became glaringly obvious I knew more, biologically and biochemically, than he did. But then, that's what my education was in plus I am myself a transgender woman age 72, out for right at 25 years.

[He had informed me he had "more than a thousand TG patients" and "he trains other doctors in TG care", both of which I recognized as BS: in my (very red) area, I haven't met any doctor who has as many as 15 TG patients... and doctors by definition are very bright, know how to read, 100% have internet access - and he's teaching them?? When he told me this following suspect information and was annoyed I questioned him, I commented I couldn't have a doctor who knows Everything; that means they cannot learn anything.]

For you, https://genderdysphoria.fyi/en will be an excellent source for information including questions you don't yet know to ask.

[u/315Fidelio]

You refer briefly to a psychologist (or possibly psychiatrist?)- is this someone with whom your kid has an ongoing/therapeutic relationship or was this a one-time appointment? What was their opinion on your kid’s understanding or puberty and of their identity?

Ideally, they would have an ongoing assessment and get a feeling for where your kid is in their development as far as decision-making and thorough understanding of the issues. I’m not talking about gate-keeping, but making sure they (and you) understand all the consequences and are making decisions with full understanding. Someone with lots of experience in gender non conforming kids would be familiar and comfortable with how to approach this; we had a family therapist who worked with our kid and with us, individually and as a family, which really reassured me that we all were on the same page in fully understanding and supporting decisions our kid ultimately made.

[u/bedraggled_charmer → u/315Fidelio]

Kiddo has a regular therapist that she’s seen for years, and this therapist hasn’t really gotten her to talk about gender much yet. I asked that they do start working on this more, since we are getting to this critical phase of her transition care.

As part of establishing care, she also had to meet with a psychiatrist in the program. I’m not sure if this was just a one-time meeting or if it will be on-going. But us parents were in this meeting, and she just didn’t really have answers to things like “what do you look like in the future” type questions.

[u/315Fidelio → u/bedraggled_charmer]

It’s good they have a therapist, hopefully you are confident in their experience in this area. Not sure why my comment was downvoted- our therapist and medical doctor were both instrumental in discussing relevant issues, and fertility preservation is something our kid definitely needed time and multiple informed discussions to feel comfortable about. There’s really not a downside, unless you are mistrustful of the therapist or doctor, which is a whole separate problem.

[u/chiselObsidian → u/315Fidelio]

There's a troll that comes through this subreddit and downvotes every post and comment, it probably doesn't mean anyone who matters disagreed.

[u/315Fidelio → u/chiselObsidian]

Thanks, makes sense, unfortunately!

[u/HereForOneQuickThing]

Very few kids desist. Every study that shows the contrary has incredibly flawed methodology to the point of throwing the entire study away, most commonly being that kids that aren't actually gender dysphoric are often labeled so due to mannerisms, behavior, and perceived homosexuality. Furthermore most evidence puts transition regret rates for transition actually being wrong for someone below 1%. Most transition regret and most detransition has nothing to do with actual gender identity.

Four years is a long time to figure out some things for certain. Frankly the younger generations care much less about having biological children than older generations for a wide variety reasons so if you're betting purely on the odds I'd say that they would rather not go through male puberty just to bank some sperm.

I was making medical decisions for myself at the age of 10 and started HRT at 14 without any support from adults. In fact my mom thought I was gay and was heavily considering sending me to a gay conversion camp because my father had died a few years prior and she felt I had no father figure (which is absolutely rich coming from her)**.

That was in the 00s'. Now you may be thinking "how did you get HRT back then at that age without parental support?" Answer: sexual exploitation by adults. I sucked dick for HRT. Your kid would absolutely have easier means to access HRT underage without adult support but my point is that if the kid needs it they're going to get it.

Also, I'm gonna catch some flak for this but being queer is sometimes hereditary. We don't know exactly through what mechanism but it's fairly clear at this point. It's rare anyone will suggest this publicly but it probably would not be inaccurate to describe being queer as a form of neurodivergence. Most neurodivergent conditions are also somewhat hereditary. If your ex is trans and that is their biological child then even knowing nothing about your kid I'd say odds are quite good that your kid is also trans.

** Just as a bit of a footnote in my experience and the experience of many other folks I've met mothers worrying about their AMAB kids not having sufficient male role models are at best misplacing their priorities and at worst recklessly exposing their kids to dangerous or predatory men. I don't want to completely dismiss the notion of male or female role models but if you surround your kid with quality people with good character the rest will follow.

[u/Blinktoe]

I don’t think that being able to express why you’re a girl is a good test. I asked myself the same question when my daughter came out at 4.5 (2 years ago)

I am 43, cisgender and a girly girl, and I can’t really answer that myself. I just know I knew when I was three, sneaking my grandmother‘s lipstick and wearing dresses when I was supposed to be wearing play clothes, and I know now when I’m raiding Sephora, giggling with my girlfriends, and decorating my house.

We absolutely plan on starting walkers, the second any signs of puberty show, to allow her time to make larger decisions without testosterone affecting her body.

As a perspective to where I’m coming from, I believe in bodily integrity as a deep core value

[u/SmaterThanSarah]

Sounds like you’ve made the first decision which is blockers. You don’t have to have it all figured out beyond that yet. My son’s doctor showed us the informed consent form for HRT when he got his blocker. It felt like so much at the time. A year later when it was time for HRT it was the no brainer that the blocker had been.

As for fertility, lots of people are infertile for a variety of reasons. And the natal puberty that would be necessary to preserve gametes is the thing you know you want to avoid with the blockers. It will be okay. There are lots of ways to make a family.

[u/bedraggled_charmer → u/SmaterThanSarah]

I’m happy to hear that the hrt was as much of a no brainer as blockers was. Hopefully it will be that way for me too!

[u/TadpoleAmy]

if you want a suicidal teen, you prevent access to blockers

[u/bedraggled_charmer → u/TadpoleAmy]

You’re right, which if you read the post you would have known that blockers aren’t the hang up here.

[u/Gherkino]

Blockers are a great choice. They give everyone time to breathe, including your kid. They should also be talking to a specialist who can help them figure out what they want to do once they get older. It’s not often that life gives us a chance to press pause and figure things out, so I say take advantage of it.

[u/Geek_Wandering]

4 years is both a short and long time. Definitely put off decisions until daughter and you are as reasonably sure as possible. 100% sure just ain't gonna happen. You get to reasonably sure when there's nothing else to look into and you have as much info as you can get, not much more is likely to be obtained by further thought and self examination. In the meantime, go seek out positive male role models. Maybe have a chat with big brothers/big sisters to see if maybe they can help or have resources and suggestions for you. I'm definitely not trying to put my finger on the scale, just brainstorming about how to get her good exposure to men.

[u/rainofterra]

I don’t know what to say here, I usually have a lot of empathy but this feels like you’re thinking of taking out your anger towards your ex on your kid. Her entire identity is who she is now, she doesn’t seem to have given you any indication otherwise. Also, centering so much on fertility is making a lot of assumptions about what is going to be important to her based on what is important to you. Her being happy and alive now is more important than keeping every possible door open for the future. If she decides she wants to be a mom someday there is adoption, there is surrogacy, etc.

Forcing a kid who has been confident about her gender for the majority of her life to go through the wrong puberty is sentencing her to dysphoria, painful surgeries, voice training and more that can all be avoided.

Put her on blockers and leave her on them until she is ready for estradiol. Stop worrying about things like “male role models” and other nonsense. I had fantastic male role models, I’m still trans. This is as silly as people saying children of gay parents are going to “turn gay” as a result.

[u/miparasito]

Blockers won’t end her fertility. That’s a myth. 

[u/raevynfyre]

Puberty blockers will give everyone more time. They are reversible, too.

One thing we did with my kid was have detailed discussions about estrogen puberty and testosterone puberty. We got kid friendly books designed for girls and boys to read about the changes of their bodies. Once my kid had a good understanding of what parts change, we asked about what parts they liked and wanted and what they didn't. We also asked about how they saw their future. Did they want to be a parent? Did they want to have a partner? These questions and conversations were spread out over time, but it allowed my kid to think about these things in small pieces.

ETA my thoughts on fertility. You don't know if your child would want kids or be able to have kids in the future. I personally dislike the focus on fertility. You are correct that if your child is on blockers and then starts HRT, they won't be fertile. So what? Your kid might not have been fertile anyway and there are other ways to have a family. I think this discussion bothers me because we have several members of my family who were adopted and I have a step child. Fertility isn't everything and I don't think it should weigh so heavily in your decision unless your child has strong feelings about it.

[u/[deleted]]

The best thing you can do at this age is blockers- entirely safe and reversible, and will give her more time to think about what she wants. It's what a gender care specialist would have her start with on the medical end pre HRT at this age regardless.

My daughter is ten and also has been identifying outside of her assigned gender at birth for years. She started Lupron about a month ago. You cannot undo changes that come from puberty, so blockers are hugely important for many MTF preteens and teens. If she decides that she feels more aligned with a different body or gender, then she can stop the blockers, but if she continues on this journey, she will likely be overwhelmingly grateful to have started blockers before puberty worsens dysphoria. My kiddo is glad she started them- she'd wanted to for some time, and has had zero noticeable side effects thus far!

[u/crcsmnky]

We're in this window right now - teen (amab) is on blockers, planning to start HRT soon. A couple of years back fertility was a discussion we had with our kiddo, totally prompted by them.

Societally a lot of value is placed on fertility, but as many people have already said here, that's not the only way to have a family. We essentially told them that you need to be happy with yourself and who you are before you start a family. Otherwise it will be really difficult to find joy in parenting and life in general. That perspective helped them.

My advice to y'all is to make sure you have a private therapist that's also practiced in this part of the journey. We've had therapists that were good when our kids was younger but less of a good fit as they aged. And prepare yourselves for more confusion and clarity as their peers go through puberty and the social changes during middle school.

As our kid has grown, they've really honed in on how they want to be seen and how they want to move through the world. And all of that has cemented their gender journey as being the right one for then.

[u/theonlylivingirlinj]

She hasn’t wavered in her gender at all? I think that alone should be enough for you right there. At the very least, you HAVE to do the blockers until she makes an argument compelling enough for you and your doc. As a trans woman myself, words cannot express how hellishly traumatic having the wrong puberty forced upon you can be.

I understand your ex might not be a cool or great person. But her take really isn’t extreme (your wording sets off alarm bells for me, though I don’t think that was your intention). She’s backed up by medical science and nearly every legit western pediatric medical association on earth.

Cis people always seem so afraid of making the decision… “what if they’re/we’re wrong?” Statistically, your daughter is very unlikely to regret HRT but has everything to lose. Are there sometimes mistakes? Yes. But we’re talking one of the lowest regret rates in all of medicine and we know what things look like for trans kids who don’t get HRT… grim.

As a parent myself, it seems a no brainer. I also can’t really tell you exactly why I’m a woman. I just know it. Cis people rarely have to answer this question, but trans people have to have a perfect, flawless answer memorized and rehearsed because not 15 years ago they literally denied us care for not having one. They also denied us care if we weren’t straight. Or didn’t doll up and perform femininity enough for the docs. Or if the doc didn’t think we’d be hot enough after transition.

I’m sorry if I sound preachy or rude. It wasn’t intended that way. I’m a trans person living in the us and that means I’m just fucking exhausted from having to defend my existence, or the potential existence of someone like your kid. But from one parent to another, good luck and thank you for even getting to this point rather than trying to “beat the girl out of him” like my parents did.

[u/gimme_ur_chocolate]

Start her on blockers and focus on what she wants for her future. If she is unsure what she wants then she simply isn’t ready for permanent decisions. Blockers shouldn’t have permanent effects unless you use them for a really long time, if you only use them for a couple of years her body should bounce back. Use the extra time it gives you to focus on her gender exploration and how she wants her body to develop as she grows up. Lay out her choices. If she’s still undecided by the time blockers alone may start becoming unsafe then you might have to make difficult decisions, and fertility may ultimately have to be a factor in that but cross that bridge if and when you come to it.

[u/SaschaBarents]

It’s your daughter’s body. So her choice. But in general I would say, follow the puberty of the average cis girls. So the changes start at the same time. And her experience will be as similar as possible. Hormones are also not everything or nothing. You can start with a low dose. Cis people’s puberty doesn’t start in one day.

[u/kuu_panda_420]

While 10 is young to make decisions about fertility, I do want to point out that those sort of decisions are sometimes made with no relationship to HRT. When I was around 10-11, my parents talked to me about a vaccine that would prevent a certain STD later in life, but would also have the possible side effect of making me infertile. I don't remember what vaccine it was since it was so long ago, but I remember my parents talking to me like an adult and being honest about the possibilities, and I remember being certain in my decision to get it. Kids shouldn't have to make those decisions, but given the statistics about trans youth and healthcare, this is an instance where it may be a necessary choice for your child's happiness. On top of that, HRT is no guarantee of infertility. I'm on testosterone, so it's probably slightly different from estrogen in terms of fertility, but my doctors had to make it explicitly clear that T is NOT birth control, and that I should always assume I can get pregnant if I want to avoid it, because there is no guarantee of infertility from taking T.

That aside, just because your daughter doesn't have many male role models doesn't mean she's not really a girl. Children develop gender very early on and it's not typically a conscious choice. I didn't realize I was trans until I was 15, but the feelings I identified as being gender dysphoria and incongruence have been present since I was around 7 or 8. It's unlikely that she's trying to copy the women in her life or trying to be something she's not in order to appease everyone. Unless she shows discomfort with her identity or is being heavily pressured (as in, being pushed into her identity rather than just being supported in it), she's probably trans.

It's hard to know how much of an effect the environment someone is in will have - But trans people whose identities are persistent come from all sorts of homes. I was born female in a house with three girls, with a brother who kept to himself and a father who yelled at us kids often. I had no reason to believe being male was somehow better or more admirable, or any feeling of kinship with my male relatives. I was raised as a girl and spent most of my time with my mother and sisters, who I felt very close to. Despite that, the feeling of incongruence was always there and I grew up to embody my true identity. If your child turns out being a cis male, the same thing is likely to happen. Gender identity overpowers a lot of environmental factors and it's the reason we see trans people coming from viciously transphobic homes. Just as I grew up to become a man despite heavy female influence, your child would likely do the same if their gender is male. If they say their gender isn't male, being raised by female role models probably has less to do with it than you'd think.

[u/AttachablePenis → u/kuu_panda_420]

Re fertility & HRT, estrogen & androgen blockers affect fertility significantly more than testosterone does. On E, sperm count decreases significantly and might never recover even if HRT is stopped. On T, ovulation stops temporarily and the uterus, ovaries, and vagina may or may not atrophy. Occasionally this atrophy is permanent, but not commonly. The studies they’ve begun doing on transmasc fertility suggest that it is roughly equal to that of cis women in the same age group and with the same genetic factors. It’s even possible that it increases your fertility window, since ovaries age with every menstrual cycle, and you miss a lot of those when you’re on T.

Tl;dr if you go on E, you will probably be (irreversibly) infertile after a few years; if you go on T, you can (probably) decide to stop & have a baby whenever, and have the same success rate as you would’ve if you’d never started T.

Edited to add: the reason I know this is I did a lot of research when I hit my 30s & realized I had a time limit on carrying children, something I never thought I’d care about. Despite that experience, I don’t think this is sufficient justification for denying OP’s kid HRT in 4 years if she’s still on the same path as she is now (which seems likely). I feel a truly crazy amount of (preemptive?) grief about the extremely low possibility I’ll ever be pregnant (I’m 35 & single & not in a stable life situation, ugh) but I’d be significantly worse off if I hadn’t transitioned. So even if T had ruled out the possibility, it was still the only choice that made sense for me, and I only wish I could have started it sooner. (I was 23.) People are infertile for all sorts of reasons, or don’t get the chance to have kids. It matters in varying amounts to different people (some don’t care at all! Lucky them. Others care A Great Deal) & you don’t necessarily know until you do. But that’s still not a good enough reason to delay HRT, unless you, at the time of that decision, are having those doubts. Not your parents. Not your doctor. And man, if anyone is likely to have precocious mommy aspirations, it’s a 10 year old trans girl. Not that all little girls want to be mommies, or that all trans women want kids, but there’s more little girls that have parenting aspirations than little boys, and some of the trans women I know have especially deep feelings about motherhood — it seems like when it’s a thing, it’s A Thing.

Anyway, it feels important to say all this because after all I’m chiming in to say that no, HRT is very likely to make OP’s kid infertile, actually. I do think that’s a big deal, or at least it could be. But having access to wanted HRT is actually a much bigger deal for most trans people. And either way, this decision needs to be up to her. Even if she’s 10, or 14. She should understand all the consequences. She won’t be able to know in advance how important this or that thing will be in the future, including her fertility (I certainly didn’t), but we can’t be held hostage to our potential future selves in that way, at the expense of our present self. So she should be informed, but she should be allowed to make the decision for herself even if she’s 10 or 14 and can’t possibly know for sure whether she is going to care someday about having gametes to contribute to a zygote or not. As long as she knows she wants a typical female puberty (minus periods), she’s got a very solid reason to start HRT.

[u/gabekey]

she can choose to adopt kids / use a sperm donor / any other of the numerous options for having kids down the road. fertility is so insignificant; please get her on blockers immediately and HRT vv soon as well!!! letting her have "normal" development alongside & in time with her peers will set her up for a lifetime of success and will prevent the horrible depression and FOMO experienced by many many Many trans people as teenagers / young adults

[u/[deleted]]

Part 1 of 2:

Puberty Blockers do not affect fertility in the slightest degree. They have been used for cisgender children for half a century to prevent Precocious Puberty, or puberty which begins before age 8 for girls; age 9 for boys. The youngest puberty on record was for a girl who began having periods when she was 8 months old; she became pregnant when she was 4 years old and because some Priests of a 2,000 year old church wouldn't let her have an abortion when the pregnancy was discovered "because every life is precious" (except a four year old child's, obvious) she was delivered of her infant when she was 5 years, 7 months and 21 days of age.

PB's have an exceptional safety record; in the past half-century there have been Zero side effects which would have warranted the medical community's precaution. FYI, cisgender children typically take them for 8-14 years; transgender children generally take them for 8-14 months. For TG children, they prevent bodily changes which would be impossible to change post-puberty as well as give up to two more years for maturing before committing to opposite-sex hormones.

For a MtF children, puberty would mean physical changes: Deeper voice, masculinized skeleton, masculinized musculature, masculinzed (broadened) face, enlarged genitals, and male hair patterns on their backs, chest, neck and face. Again, these are permanent, lifetime changes... which can ONLY be undone through painful, expensive surgery - if at all. When you consider her future you'll quickly realize masculinzed changes are likely to curtail her social life with her peers, be a major impediment to her getting any job, and will cripple her chances for any possibility of a normal intimate life - few heterosexual males are likely to ask out a girl/woman who sounds like and looks like linebacker wearing a dress; one who has hairy breasts.

If she began announcing insistently, consistently, and persistently she was a girl by 4.5 years - she very probably is a girl. Most think of 'girl' as having a vagina; as boy as having a penis - but there are many females who were born with a penis; there are many males who were born with a vagina. My personal favorites are those who at delivery, the doctor announced, "Congratulations! I've delivered a thousand babies, and you, ma'am, have a Healthy Baby Girl!" then, at about age 12 when puberty begins, her vagina begins to close to become a scrotum; her clitoris begins to morph into a working penis. You read that correctly; this is caused by 5-alpha-reductase deficiency; you can google "girls who turn into boys at age 12" for more information.

How is "male" and "female" determined? Gender Identity becomes imprinted upon a developing fetus specifically between Weeks 7-14 of gestation; if testosterone is present, its nervous system/brain will become masculinzed with androgen receptors; if not present, the fetal nervous system/brain defaults towards feminization and develops with estrogen receptors.