Gender-affirming care for minors

In Singapore, gender-affirming care for minors (under 21) requires the consent of both parents, even if those parents are separated.

Exceptions may be made for extraordinary circumstances (e.g. if one or both parents are dead or mentally incapacitated).

There is no minimum age to be evaluated by a psychiatrist for gender dysphoria (which is required for HRT), although parental consent will be required for those under 18.

After receiving a diagnosis of gender dysphoria, trans youths with both parents’ consent can access HRT through private healthcare if they are above 16, and through public healthcare if they are above 18.

Obtaining gender-affirming care for minors

The private healthcare route

• If you have your parents’ support and they can afford it, you can visit a private psychiatrist to be evaluated for gender dysphoria. This will likely require several sessions, with each costing a few hundred dollars. Some psychiatrists are also able to speak with your parents to explain what it means to be transgender and address concerns they may have.
• Once your psychiatrist has deemed you suitable to begin HRT, you can then visit a private endocrinologist. Note that private endocrinologists may have their own age requirements.
• If you are above 18, you can also bring the psychiatrist’s diagnosis to a public hospital endocrinologist (via a polyclinic referral if you are a Singapore Citizen or PR), but results may vary as they may not accept diagnoses from private psychiatrists.

Through the public healthcare route

• If your parents are supportive, you can visit a polyclinic and request for a referral to a psychiatrist for gender dysphoria. It is likely that you will be directed to a child psychiatry clinic for evaluation.
  • HRT approval for trans youths under 21 is much stricter, especially given the global climate with regards to transitioning for trans youths. You will be subject to a lot more evaluation than trans adults, and there are people who have been rejected for HRT despite having both parents’ consent.
  • If you are under 18, you may receive a diagnosis but will need to wait until 18 before you can begin HRT even if both parents approve.
• If your parents do not consent to HRT, you can still use these appointments later on as supporting documentation to gain accommodations (e.g. for National Service)

Puberty blockers

A minority of transgender youth who desire medical transition and who have been assessed by doctors as suitable candidates for treatment may choose to undergo temporary puberty suppression with puberty blockers. This will solely halt the development of secondary sex characteristics, allowing them time to physically and mentally mature before making the irreversible decision to undergo either typical male or female puberty.

Subsequent HRT will then allow them to develop bodies that – genitalia aside – are phenotypically identical to others of their gender. Trans women will be able to retain high voices; trans men will not have to grow breasts. Both will develop the height, musculature and skeletal structure typical for their identified gender. This eliminates most sources of body dysphoria, increasing quality of life. It will also make it much easier for them to blend into society, significantly reducing their risk of discrimination, abuse and violence and give them the ability to live a normal life, should they so choose.

At this point, assessments are rigorous enough that roughly 98% of these youths persist in trans identification as adults, indicating that non-treatment is far more likely to do harm than good, and allaying common fears that many may cease to be trans in adulthood.

The remaining 2% include those who are still trans but have decided not to medically transition at that point, those who realise they are non-binary, and a few who no longer consider themselves trans. These youths can then go off the blockers and proceed with regular puberty, retaining their fertility, and will likewise look no different from others of their sex.

A large scale study of 20,619 transgender adults aged 18-36 found that past access to pubertal suppression, for the 16.9% who desired them (2.5% of that subset had access), was associated with reduced lifetime suicide ideation and improved mental health outcomes.

Prior long-term studies of transgender youth who undergo puberty blockers treatment have consistently produced extremely positive results. In one study, 55 transgender youth were monitored over a period of about 8 years from the administration of puberty blockers at an average age of 13 to hormone therapy at ~17 to surgery at ~21, after which they scored equal or better on assessments of mental health compared to their non-trans peers. This is especially significant in light of the astronomical rate of mental illness and suicide that has long been observed in transgender youth denied treatment until adulthood.

As with all medication, there is a risk of side effects. Each youth’s individual health profile, existing conditions and family medical history are thus also taken into consideration alongside the severity of dysphoria and other concerns. These risks may need to be separately monitored and managed as appropriate.

Side effects are more common with extended use of puberty blockers over many years, as is the case for children with precocious puberty, and it is not recommended to be on them for more than 2-3 years. Where a youth has been on puberty blockers for several years or experienced concerning side effects, had found relief from dysphoria through the blockers, and has expressed a strong and persistent gender identity across many years that shows no sign of changing, earlier access to HRT may be considered appropriate on a case-by-case basis.

Puberty blockers are not available in Singapore for transgender youths in the public health system. For information on how you can obtain puberty blockers through a private specialist, reach out to us at contacttransgendersg@gmail.com.

Things to consider for trans youth

There is no single “right” way to transition

Some trans people experience little or no body dysphoria and are content with social transition without medical intervention. This is especially common for those who are non-binary.

If this is the case for you, and you are happy with your body as it is, you should never feel pressured to pursue HRT out of the belief that it is what a trans person “should” do. The goal of transition is for you to be comfortable with your body and identity.

If you are happy with yourself as you are but feel that you need to look a certain way to be taken seriously as your gender, that is a valid concern, but should not be the basis for medical decisions. Consider speaking about this with a counsellor, or find other ways to influence how others see you – such as through make-up (for trans girls and other transfemmes) or working out (for trans boys and other transmascs), or even explicit indicators like pronoun pins. For trans youths, this – alongside clothing, hairstyles and mannerisms – may be sufficient for you to be perceived as your gender.

Schooling

Socially, trans students in Singapore face immense challenges within the school system and are unlikely to be accommodated on issues of uniform and toilet access. If you are presently enrolled in a local public school, you may wish to consider options like withholding your transition until after graduation, living as your gender only among friends or outside of school, or going on HRT without full social transition if your dysphoria is too severe.

• This could look like a trans girl going on HRT to ease her dysphoria and coming out to friends and classmates, while continuing to wear the boys’ uniform at school. This is often harder for trans boys, who would stand out more in the girls’ uniform if they are on HRT, but some schools are willing to make accommodations to allow PE uniforms instead.

If you legally change your name, you can update your name in your school records and be addressed as such. Schools would otherwise continue to refer to you by your legal name, which would also be the name that appears in your transcripts and certificates.

International schools are known to be more accommodating and even strongly supportive of transgender students. This nonetheless differs from school to school.

Managing stress

Transitioning is often deeply stressful, especially in Singapore and especially for youths, all the more if you do not have a supportive environment. If you are already undergoing considerable stress in other areas of your life, do take that into account when considering when and how to transition.

• If you have severe gender dysphoria, the relief from transition may help you better cope with stresses in other areas of your life, even alongside the new challenges that will come from transitioning.
• If however your gender dysphoria is minimal, the relief you get from transitioning may not be enough to overcome those additional stresses and challenges. In that case, you may wish to wait until you are older, since transitioning as an adult over 21 is much easier in many ways and also gives you more control over your own transition. This is especially important if you desire a less typical transition, such going on low-dose HRT or pursuing surgeries without HRT.

What you can do in the meantime

It is difficult to access psychological care and support for gender dysphoria without parental approval. However, some services have a lower age limit – support and befriending services begin at 16 for TransBefrienders.

If your parents can afford it and are open to it, you can ask to go to a LGBTQ-affirming counselling or therapy service. Some provide family counselling sessions that you can attend together with your parents

Coming out to parents – I’ll Walk With You

I’ll Walk With You is a comprehensive resource guide for parents of transgender children and is available in all four of Singapore’s official languages – Malay, English, Chinese and Tamil.

It is available in PDF form here.

If your parents would like additional support, they can also reach out to us for information.

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Due to the sensitivity of the information involved, feel free to contact us if you wish to find out more about pursuing transition via the public healthcare system. You can reach us by email at contacttransgendersg@gmail.com.