Transgender Youth: Providing Medical Treatment for a Misunderstood Population
By Stephanie Brill and Jennifer Hastings, MD
It is another one of those times in the history of progressive health care. Time to embrace another group of individuals who deserve health care and yet have been marginalized up until this point. An underserved, unrecognized, and much deserving segment of the population. This time it is children — transgender children and teens.
Because of society’s lack of awareness of a simple, yet complex part of human identity — gender — transgender children and teens are deeply misunderstood. This lack of understanding feeds family and societal rejection and stigmatization, which unfortunately too often leads to sexual and physical violence directed towards transgender children. A known, or recognizably transgender person is frequently a target for discrimination and violence. The shame and rejection felt by these children in turn leads to self-harming behaviors, increased drug use, homelessness, HIV/AIDS infection, depression, and suicide. One-third (33.2%) of transgender youth have attempted suicide.1
Although it is unknown how many children and teens are truly transgender, medical professionals and others who care for children are finally paying attention to this minority group. Doctors in the United States, the Netherlands, the United Kingdom and elsewhere in Europe now agree that early treatment of transgender children can change -- and even save -- lives. In order to understand what kinds of treatments are needed for transgender children and youth, it is important to understand what a transgender child is, what treatments are available, and how these treatments can help.
What is Transgender?
Transgender people have existed throughout all times and in all cultures. Being transgender is not a mental illness but is, rather, a normal variation of human development. There is nothing wrong with transgender children -- the problem lies with the way we understand gender.
Common understanding of gender is based on the premises that there are two genders. and that gender and biological anatomy are synonymous. Each of these premises is incorrect. In fact, a minority of the population experience themselves as either a blend of genders or no gender at all. For most people, gender is static. For some, however, it is fluid or changes over time. Likewise, one’s biological anatomy determines one’s biological sex. One’s internal sense of gender, however, is not determined by biological anatomy but is a different spectra of formative identity altogether. Taken together, biological sex and gender identity create a person’s sense of “self”. Because it is most common for biological sex and gender identity to align in a predictable pattern, the two separate aspects of “self” have become conflated. In order to understand and serve transgender people, however, it is essential to recognize and distinguish these separate parts of self.
In other words, although it is most common that people with female anatomy identity as girls, a small percentage do not. Of those who do not feel they are girls, some identify as a blend of genders, some as neither gender, and some identify as boys. A female-bodied person who identifies consistently and persistently over time as a boy is a transgender boy. Likewise, although most male-bodied people identify as boys, a small percentage do not. A male-bodied person who identifies consistently and persistently over time as a girl is a transgender girl.
We do not have accurate statistics to reflect how frequently transgenderism or significant gender variance occurs. There have always been transgender children, but in the past the family was likely to deny what was happening, to allow their child to transition but hide this fact from others, or prevent the child from living as their true self until they left home. Awareness of this population is just coming to light, and more parents are openly supporting their children at younger ages. An indicator of this rapid societal shift is the fact that five years ago, Gender Spectrum was called to do trainings in support of transgender children one to three times a year. In 2009, Gender Spectrum was called to support transgender children 10-15 times a week.
How can you know for sure that a child is transgender?
There are many children who are gender-nonconforming in their appearance or interests who still have a gender identity that is congruous with their anatomy. These gender-variant children are usually gender-nonconforming in their self-expression, but still feel that they are in the right-gendered body. For example, Gender Spectrum frequently provides school trainings for anatomical boys who identify as boys but want to wear dresses to school. These boys are perceived to be girls, due to their appearance.
As children and teens, these youth often experience a tremendous amount of ridicule and shame for being “different”. Yet, it is important to note that the majority of gender-nonconforming children are not transgender. While they require support and understanding for their gender variance, they do not require medical intervention. Medical providers are uniquely poised to assist transgender children who want their bodies to be perceived as congruous with their inner gender. Medical providers can guide these youth and their families through the process of deciding which medical treatments, if any, are appropriate for the specific child. Likewise, medical providers can provide all gender-nonconforming youth and their families with effective tools and guidance to encourage self-esteem and the courage to continue being themselves.
One of the challenges for parents and caregivers alike there is no way to be 100 percent sure that a child is truly transgender. There is no test to determine if a child who insists over time that he or she is not the gender assigned to them at birth is going to feel the same way as an adult. But, the overwhelming majority of transgender adults report that they knew that they were transgender from the time they were children. The longer a cross-gender identification “phase” persists, the less likely it is to be a phase. So, parents and clinicians alike rely on a combination of the child’s experience, the parents’ perspectives, the longevity of the gender variance, and psychological assessment to determine if, and when, it is time to validate a child’s experience of their own gender with medical intervention. One California parent describes their experience, saying: “We had always allowed our daughter to express herself in the ways that felt right for her. When she was young – two years old -- and told us she was a boy, we naturally assumed this was a phase. At first we neither encouraged it nor discouraged it. We essentially ignored it. However, this phase has yet to end! It has been eight years now. After a while, we no longer ignored it and, with the help of a therapist, we allowed our child to change pronouns and live as a boy starting in kindergarten. He is now half way through fifth grade. Our son has always been our son- it just took us a few years to understand this. We fully support him and will whatever it takes for him to live a happy and successful life.”
Because of the difficulty in determining if a child is transgender, it is vital that health care providers familiarize themselves with the current literature regarding gender variance and children. This will help them provide sensitive care to their patients and help support families in parenting these children. Studies have shown that acceptance and support from parents and other caregivers are very important to long-term positive outcomes for transgender children. An informed medical professional can help parents and children address transgender feelings and ensure the best possible future for the child.
When a family feels certain that their child is transgender, they should be encouraged to allow their child to socially transition. This means that the family allows the child to live as the gender the child feels himself or herself to be, rather than insisting that they live according to the gender assigned to them at birth. Seeing the devastating impact on their children of living as the wrong gender, more and more parents are allowing their child to socially transition genders at younger ages. Some children go through a social transition prior to kindergarten, while other children (or their families) are not ready to do so until middle or high school. Ideally, this process occurs with the support of a therapist, pediatrician, and with appropriate training for staff and teachers at the child’s school.
Puberty for the transgender child
For many transgender children, the arrival of puberty brings with it a crisis. In puberty, the body enters into changes that mark the individual as male or female. For transgender people, this process means that they will permanently be a member of the sex opposite to the one they experience themselves to be. The suicide rate for transgender teens is exorbitantly high due, in part, to these body changes.
Medical suspension of puberty
Some of puberty’s changes are later reversible through surgery and medication. Others are not, however, and may permanently mark the transgender individual. For this reason, hormone blockers are now being used to suspend the natural development of puberty by inhibiting the pituitary’s release of gonadatropins. The medications are called “GnRh agonists” and are fully reversible. Within six months of discontinuing GnRh agonists, the patient’s body resumes puberty at the point it left off.
One of such a suspension’s great advantages is that a child, family, and gender team can effectively press a “pause” button on puberty and gain the time necessary to determine if the individual would benefit from administration of cross-sex hormones. Suspending puberty is especially helpful for a pubertal or pre-pubertal teen who has recently revealed to their family that he or she is transgender. The suspension allows the family time to come to terms with what the child is saying and establish whether he or she is truly transgender before committing the child to unwanted physical changes. It also decreases the likelihood that the child will resort to street hormones or suicide to cope with the agony caused by living in the wrong physical body. These fully reversible medicines are lifesavers, and all medical providers working with older children and adolescents should become familiar with their purpose and function.
When followed by cross-sex hormones (described below), GnRh agonists are a powerful tool that can be used to permanently prevent development of the “wrong” puberty in a transgender child, thereby eliminating the need for future surgeries and reducing societal stigmatization. Some practitioners have ethical concerns about administering these medicines because they fear they are interfering with destiny or are afraid of legal concerns stemming from suppression or redirection of puberty in a minor. In gender clinics in the U.S. and around the world, however, puberty-blocking medications are being used without any adverse effects being reported, and with full reversibility of their effects. Because these medicines may save lives and reduce trauma, some feel the medical provider has an ethical mandate to provide them.
Testosterone and estrogen are the hormones responsible for puberty. These hormones stimulate the development of physical characteristics we associate with men and women. These natural hormones can be administered as cross-hormonal medicines to a body that desires physical changes that would not normally occur. Administration of estrogen to a male body causes the skin to soften, fat to be redistributed to the hips and thighs, and breasts to develop. Estrogen also suppresses development of secondary male characteristics such as deepening of the voice and hair growth. Administration of testosterone to a female body causes the voice to deepen, development of male hair growth patterns, muscle mass to increase, and fat to be redistributed to the abdomen. Testosterone also suppresses the menstrual cycle and breast development. These medicines are well-researched and have been used in youth to treat delayed puberty for many years; protocols for administration and follow-up care are established, as well.
The decision to administer cross-sex hormones to a transgender child or youth is often more complex than the decision to administer puberty-blocking medications. This is because some of the changes from cross-sex hormones are irreversible (i.e., hair growth patterns, lowering the voice), while others can only be reversed through surgery (i.e., breast growth). For this reason, it is essential that cross-sex hormones only be administered when the individual is ready to begin the transition to the correct gender. Written communication from the child’s primary care provider, therapist, or another experienced mental health professional can help document and confirm the patient’s clear transgenderism and readiness to transition medically.
The ideal age at which to administer these cross-sex hormones is not firmly established A child can stay on the puberty-blocking medication for years, if needed, before receiving cross-sex hormones. However, the benefits to a transgender youth of being able to go through the “right” puberty at the ‘right’ time are tremendous. For this reason, once transgenderism has been established, and the youth is of pubertal age, many gender specialists believe that it is appropriate to administer cross-sex medicines. In other words, it is best to slowly initiate cross-sex hormones at the same time that the patient’s peers are entering puberty, typically around age 12--14.
Support for Parents and Family of Transgender Children
Parents, other family members, and friends of transgender children need support as much as the transgender child does. It can be very challenging to come to terms with having a transgender child and become an advocate for their health – but doing so is it immensely rewarding and essential for the child’s health. Supportive parents may suffer rejection from friends, family members, or co-workers who do not understand why they are embracing their child’s transition. In addition, it can be hard to find qualified mental and physical health providers, and to gain the support of the school system. Parents often find themselves forced to educate their child’s doctor and school staff. The parent of a transgender youth also faces daily challenges that include remembering to use the appropriate gender pronoun, coping with unexpected “outings”, and addressing both their own and their child’s emotions. Luckily, a growing number support groups now exist throughout the country, and the Internet, on-line support groups, and books offer vital support for families.
Relative little research exists on outcomes for gender non-conforming youth. But, individuals from the fields of medicine, mental health, social work, and education consistently report the same findings: when supported by their families, schools, and care providers, transgender youth have the opportunity to thrive and develop strong self-esteem. According to groundbreaking research from the Family Acceptance Project, the way that parents and caregivers respond to their child’s gender variance is the most significant marker of long-term health and well-being.2 We cannot change a child’s gender identity, but we can directly impact how a child feels about their gender identity.
Brill S and C Ryan, Early Childhood Development - Your Options - How Do I Know If My Child Is Transgender? National Association of Social Workers website: http://www.helpstartshere.org/Default.aspx?PageID=1114
Reed BWD, Cohen-Kettenis PT, T Reed et al., Medical care for gender variant young people: Dealing with the practical problems, Sexologies 2008; 17(4): 258-264.
The following materials and other resources can be found at: http://www.hawaii.edu/hivandaids/links_transgenderYouth.htm
Stephanie Brill is the co-author of The Transgender Child: A Handbook for Families and Professionals. She is also the founding director of Gender Spectrum, which provides support and training to families, medical and mental health care providers, and educators about gender in children and youth. She is the co-founder of MAIA Midwifery and Preconception Services, and the Oakland Children's Hospital’s support group for parents of gender variant and transgender children. She speaks and trains on the developmental stages of gender variance in children for medical and lay audiences and can be reached at www.genderspectrum.org.
Jennifer Hastings, MD is a family physician working at Planned Parenthood Mar Monte in Santa Cruz, CA. She started a Transgender Healthcare Program in 2005, and works closely with Shane Hill, PhD and the Santa Cruz Trans Therapists Team, providing comprehensive Transgender Care. She is working to expand Transcare Services to other Planned Parenthood clinics.
1. Clements-Nolle K, Marx R, Katz M, “Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization,” Journal of Homosexuality 2006; 51(3):53-69.
2. Ryan C, Huebner H, Diaz R, et al. “Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults,” Pediatrics 2009; 123(1):346-352.