Does prepubertal medical transition impact adult sexual function?

by Brie Jontry

Brie is a public spokesperson for 4thWaveNow. She can be found on Twitter @bjontry. To learn more about her, read her interview, “Born in the Right Body.” 

All audio clips (click to listen) are from the Gender Odyssey conference in Seattle, Washington, August 2017.


A few months ago, I watched a YouTube video made by a young non-binary person who couldn’t orgasm. Born female, their natal sex hormones were suppressed in late puberty and testosterone followed. While I knew “puberty blockers” (a gonadotropin-releasing hormone agonist) followed by cross-sex hormones stops future sexual development in males–and sterilize both sexes–I realized I didn’t know anything about how this process affects females and their future ability to experience sexual pleasure.

GnRH agonists suppress 95% of all sex hormone production. For a “vagina-haver,” low levels of estrogen, LH, and FSH can mean vaginal atrophy, or life with a potentially very dry, possibly itchy, thin-walled vagina that is more prone to bacterial infections, bleeding during sexual activity, and urinary incontinence, among other annoying-to-serious health issues. Estrogen keeps mucous membranes healthy and pelvic floor muscles strong.

I read a number of studies that found  “sexual desire, sexual interest and sexual intercourse were totally annulled” during GnRH use in male cancer patients and repeat sex offenders, and that females, sent into “chemical menopause” after being treated with Lupron for endometriosis, experienced even greater decreases in libido, sexual function, and ability to achieve sexual pleasure than women in natural menopause. This could be because during natural menopause, LH and FSH hormones, which are important to emotional well being and sexual desire, surge, but they are also suppressed by GnRH agonists.

I turned to the Facebook group frequented by members of WPATH, hoping to find more information. Surely members of the World Professional Association for Transgender HEALTH would be concerned with protecting young people’s’ abilities to function sexually as mature adults, right?

My search for “orgasm + blockers” turned up six posts. None about what happens to female bodies. The first and most pertinent post is this one (click to read the whole conversation), written by a therapist who has helped “100s of kids transition” and who is also an aunt to two trans teens. In reading her posts, I usually find this therapist to be thoughtful, with sincere concern for teens’ well being, and I was glad she was the one asking (even though it is concerning she’s helped so many kids down this path yet required a “sophisticated” parent to jolt her into thinking about this question):

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None of Arlene’s very, very, smart friends were able to give her much of an answer.

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Bummer, even the Dutch don’t know. That’s when Arlene is reminded by her fellow WPATH members that dead people can’t have orgasms.

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While Arlene defends the value of difficult questions, one of the busiest pediatric gender docs in the country, Johanna Olson-Kennedy who oversees the care of some 900 plus patients at The Center for Transyouth Health and Development at Children’s Hospital Los Angeles, stops by to share a report about infant and toddler masturbation.

She tells readers that she’d “love it” if everyone could “enjoy” an “amazing article” that talks about how “of these 13 orgasming and masturbating infants and children, 5 were misdiagnosed with seizure, and on anti epileptic meds.”

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She doesn’t bother to post a link to the full text report published online in Annals of Saudi Medicine (but I will), she just uploads a sideways picture of the first page.

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It’s a sad read about the sex hormone levels in a sample of thirteen babies and toddlers diagnosed with “gratification disorder” (they masturbate. Often) who were seen at pediatric neurology clinics in Jordan. It wouldn’t be worth mentioning here except that Olson-Kennedy references this study again a year later when she talks about the population of natal males who will be forever stuck with “Tanner II genitals” during her presentation for parents: “Puberty Suppression: What, When, and How,” at the 2017 Seattle Gender Odyssey Conference. Audio of the presentation, which is excerpted below into small clips, is available in full here.

It is unclear what this study has to do with protecting sexual function in males denied natal puberty. At the conference, Olson-Kennedy explains that she “went on a journey to find out if prepubertal kids have orgasms.” But how does the study support her own practice of administering blockers and hormones to prepubescent youth? First and foremost, orgasm is never mentioned in this short report focused on masturbation. The subjects were thirteen children between the ages of 4 and 36 months, not “18 months and nine” years old, as she claims. Moreover, only three of the thirteen young ones studied were male, the group of people Arlene is concerned with in her FB post. “What if “we” get it wrong?” Olson-Kennedy asks towards the end of the anecdote, and laughs.  The “Cis Trajectory” is the problem; conceiving un-medicalized bodies as preferable, according to Olson-Kennedy, is the problem (Olson-Kennedy, Gender Odyssey, 8/25/17 8:41-9:50).

Most of us have known or heard of babies and toddlers who like to fiddle with their bits. No one should deny that even the youngest of infants is capable of pleasurable feelings when they touch sensitive parts of their bodies. Even people with immature genitals and lower levels of sex hormones can experience sexual pleasure but are these early childhood experiences comparable to adult ones? Are they ‘good enough’ for a lifetime? Do you think you’d be bitter, as an adult, if as a minor, doctors took away your potential to ever experience full adult sexual pleasure? I would be, yet it appears Olson-Kennedy is suggesting that since very young children masturbate, parents shouldn’t worry about the potential loss of sexual function that results from GnRH agonists used in early puberty and followed by cross-sex hormones.

We need to talk about this more, even if it is uncomfortable. Our children have a right to grow into bodies capable of experiencing full sexual pleasure. The organs responsible for fertility are also those responsible for sexual function. Locking people into an adulthood with prepubescent sex organs–or a need for genital surgery–should be a focal point in all conversations about the consequences of denying children natal puberty.

These issues are rarely discussed anywhere, unless you’re lucky enough to catch Olson-Kennedy at a gender conference. Olson-Kennedy “gives prescriptions to people to masturbate” because (as she explains at Gender Odyssey conference in Seattle in August 2017),

Blocking is one tool that’s an awesome tool for a lot of people. And what does that mean? Does that mean that trans feminine, trans girls who get blocked in tanner 2 we are we are making the assumption that all of them are going to have genital surgery. Are we doing that? Because we might be doing that. (Laughs) I’m just saying we might be doing that. And so that actually is worthy of a conversation. Because many trans women do not have genital surgery. Love their genitals, enjoy their genitals, like to use them.

That’s fantastic. We love people who love their bodies and use them and enjoy them. That’s a great human place to be. But we have to ask ourselves if you have Tanner II male genitals are you going to be able to use them, are you going to want to be able to use them? Or we are we just assuming that everybody is now going to have to say “Well I either need to go through puberty to get adult sized genitals or I’m going to have these genitals that I have or I’m getting surgery.” Does that make sense?…If we are judging the success of vaginoplasty by post-surgical orgasm how do we know people are having orgasms prior to surgery if we are blocking them at Tanner II? (Olson-Kennedy, Gender Odyssey, 8/25/17, 8:41-9:50)

In another Facebook post, Olson-Kennedy asks:

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Procuring approval for vaginoplasties at younger ages is important because, only guessing here, her patients aren’t happy to “have NON FUNCTIONING genitals because they had the extraordinary opportunity to avoid “male pubertal maturation.”

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Let’s talk about that. Drugs that are successfully used to chemically castrate sex offenders, which have been shown to lower IQ as much as ten points in children taking them for precocious puberty, are now being prescribed off-label to kids in Tanner II who don’t want to suffer what Winters describes as “irreversible disfiguration from incongruent puberty.” How can adolescents or their parents make an informed decision or a balanced cost-benefit analysis about the potential for permanent sexual dysfunction when the language used to describe the natural process of development equates a body capable of ejaculation and orgasm with one that is disfigured?

We’d be reckless not to think that at least some of the bodies acted on with cross-sex hormones before they have a chance to fully develop will, at some point, seem “disfigured” to the adults who live in them and to those who might want to have sex with them. In a recent study, 958 adults aged 18-81, 87.5% said they wouldn’t consider dating a trans person.

However, even among those willing to date trans persons, a pattern of masculine privileging and transfeminine exclusion appeared, such that participants were disproportionately willing to date trans men, but not trans women, even if doing so was counter to their self-identified sexual and gender identity (e.g., a lesbian dating a trans man but not a trans woman).

How much more difficult will it be for some to find partners and sexual pleasure in their altered bodies? Does Olson-Kennedy talk about these challenges with her patients? In her talk at Seattle Gender Odyssey last year, she says she checks in with some about where they’re looking for dates. Online, she says, it’s easier to disclose and find people interested but “you may be someone’s fetish” (Olson-Kennedy, Gender Odyssey, 8/25/17 1:15:23).

I’m stuck once again, wondering how knowing all this, she still claims that her role is to “Do everything in your human power to get them what they need and deserve” (:29 – 1:14)) when they’re eleven years old and what they want may not be in their long-term best interest?

Oh, and natal females, the group that set me off on this research in the first place? According to Olson-Kennedy, suppressing puberty isn’t all that wonderful for them, either. She explains to parents at Gender Odyssey that not only are emotional lability and significant behavioral changes frequent and serious side effects of blockers (29:15) but another reason these kids are “doing so bad” is because blockers put them in menopause. I appreciate her candor,  “Menopause is bad enough when you’re menopause-age, but when you’re fourteen and you’re having hot flashes, memory problems, insomnia, and you feel like crap, it is really terrible. This is really common” she says, of the current treatment protocol. “What happens when you put a fourteen year old in menopause?” she asks the audience. “You’re shutting down their ovaries,” she answers herself (Olson-Kennedy, Gender Odyssey, 8/25/17, 30:25)

Towards the end of her talk, Olson-Kennedy briefly mentions that pelvic pain is common after 18+ months on testosterone, and that she thinks it comes from “the pelvic floor” not an atrophic uterus. She says genital dysphoria usually sets in two-three years after starting on testosterone, which also negatively impacts the health of female sexual organs, causing vaginal, cervical, and uterine atrophy. I can’t help but wonder how GnRH agonists followed by testosterone, a treatment plan that may produce a double whammy of vaginal and pelvic area discomfort, impacts an already dysphoric teen’s feelings about her body, about her sexuality? The potential for vaginal, cervical, and uterine atrophy needs to become a focus in discussions surrounding youth medical transition, and what that means for the sexual becoming of a vagina-cervix-uterus-haver (perhaps still with the shallow vaginal cavity and thinner vaginal walls of a prepubescent child).

So, why? Why, given all the negatives associated with puberty suppression and early medical transition, aren’t mental health tools like dialectical behavioral therapy, which is successful at helping even suicidal people learn to manage distress and discomfort, offered first?

Instead, Olson-Kennedy focuses on getting parents to stifle every protective urge they possess so they’ll sign off on unnecessary and harmful medical interventions for a group of children, at least some of whom sound remarkably like those categorized by Lisa Littman, Susan Bradley, Riittakerttu Kaltiala-Heino, Ray Blanchard, Michael Bailey, Tania Marshall, and 4thWaveNow parents as experiencing ‘rapid onset’ gender dysphoria:

Some present with a prolonged history of gender dysphoria but the absolute hardest are the twelve to fourteen year old trans boys coming out to their parents…they came out like two months ago, and what happens? At nine years old something doesn’t feel right. I’m starting puberty, I’m doing all this work, I’m going online, I found 750,000 YouTube videos “this is me one month on T;” I’m connected to my community; I know I’m trans; I’m twelve years old and I absolutely have to tell my parents and now my parents are here and I’m here [points far away]

And because I’m thirteen you need to get on the ball and this needs to have happened yesterday and because I am here and my parents are here [far away] and the parent desperately wants you, the provider, to close that gap by pushing their kid backwards. But you as a professional know you have to close that gap by pushing them forward and keeping them. You want to keep them because you want them to give consent and be supportive. (Olson-Kennedy, Gender Odyssey, 8/25/17, 48:30-49:50)

I didn’t find all the answers I was looking for because no one has them. There is no medical diagnosis of “wrong” or “incongruent” puberty. Denying a body any stage of sexual development as a first-line of treatment for a non-lethal condition should never be encouraged let alone celebrated. Let’s refocus the discussion on ways to help young people manage their distress that prioritizes their physical and sexual health.

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