Some children who have had gender dysphoria since early childhood experience distress at the first signs of their secondary sex characteristics. This might have a strong negative effect on their emotional and social functioning as well as on their school lives. Physical intervention should be considered for such adolescents; however, gender identity can also fluctuate during that period. Therefore, it is difficult to use cross-sex hormone therapy as a way to masculinize or feminize the body for early adolescents, because such hormones have partially irreversible effects. Worldwide, puberty suppression therapy is recommended for such pubescent children, as it is recognized as reversible physical intervention. For puberty suppression, gonadotropin-releasing hormone agonists (GnRHa), which stop luteinizing hormone secretion, are used. This consequently stops the secretion of testosterone in genetically male patients and production of estrogens and progesterone in genetically female patients; as a result, the physical changes of puberty are delayed. When GnRHa is stopped, the progress of puberty restarts. This therapy is also mentioned in the 4th edition of the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder (The Japanese Society of Psychiatry and Neurology). According to those guidelines, we can use this therapy for early adolescents after they have reached Tanner Stage 2. Although this intervention is new to Japan, there is some evidence from other countries supporting such applications. Furthermore, in Japan, pediatric endocrinologists have used GnRHa for young patients with precocious puberty for a long period of time, and this has proved the safety of this treatment for children. More experience and data in this area are needed. Furthermore, we have to establish closer cooperation with child mental health specialists, such as pediatric psychiatrists, school counselors, and teachers, so that proper treatment may begin at the right time for more patients. Psychotherapy or psychosocial support, on its own, is sometimes not enough to reduce the physical dysphoria of transgender patients, and the innate sex steroids also have irreversible effects on gender dysphoric children. When we decide not to intervene in cases of gender dysphoric children with hormonal treatments including puberty suppression, we are actually deciding to intervene by leaving them with their inherent hormones. We have to be conscious of the fact that "withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents (Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7)."
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