The term transgender has been very much in the news over the last several years, but many of us know little about the experience that makes an increasing number of young people say they are the wrong gender, and need to make a change. The experience of being transgender, or more broadly gender nonconforming, means that a person’s gender at birth (assigned gender) does not match the way they feel about themselves (their affirmed gender).
Young people who are transgender feel powerfully that they wish to be — or are — the other gender. They not only want to dress and act and be accepted as the other gender, but may feel extremely uncomfortable in their bodies, and want to change them, through hormone therapy or surgery, to align with their gender identity. Girls who transition to become males are transgender males. Boys who transition to become girls are transgender females.
The disconnect between their experienced gender and their assigned gender can result in acute distress called gender dysphoria. Gender dysphoria can be a source of profound suffering. A recent study of transgender teens found that more than 50 percent of transgender males and almost 30 percent of transgender females reported attempting suicide. Transgender adolescents are often vulnerable to bullying and family rejection. And even when families are supportive, it can be a very difficult transition for both the teen and the parents.
What is gender expression?
Gender is expressed through one’s personality, appearance and behavior — typically as either masculine or feminine. Diverging from one’s assigned gender, called gender nonconformity, can appear as young as two or three years of age, when children become aware of the notion of gender and they may assert, “No, I’m a boy,” or “No, I’m a girl.”
It’s a normal part of development for children to explore various modes of gender expression throughout childhood. Some gender nonconforming kids, when they are young, don’t associate with either male or female gender expression in things like clothing, toys, activities, preferences in friends. They stay neutral.
Others present as typically male or female and surprise their parents when they declare their affirmed gender, explains Paul Mitrani, MD, PhD, a child and adolescent psychiatrist at the Child Mind Institute who has worked with families of transgender children and adolescents. “Parents can come to you and say, ‘I don’t understand. She used to love dresses and dolls and all those things, and all of a sudden she’s telling us that she’s a transgender male.’ ”
One family’s story
Melanie is one of those parents who was surprised. Her daughter, now a transgender male named Kyle, had never been particularly girly, but Melanie was not aware of any gender issues until she was 12. But Kyle had seemed vaguely uncomfortable, and at 11 was diagnosed with social anxiety. A psychiatrist put her on an anti-depressant, which seemed to help. Then, at 12, she told her mother she thought she was gay. And she quickly told the news to everyone at school.
The summer after seventh grade, Melanie got a call from a friend’s mother, who said, “I just want you to know, your daughter is telling my daughter that he thinks he’s male. That he thinks he’s transgender.”
Melanie and Kyle returned to the psychiatrist they had seen earlier and she was dismissive of the news. “Oh, all the kids think they’re transgender now,” as Melanie recalls.
“I thought it was really hurtful, Melanie said. “She basically scoffed. It was like a guffaw. I think it taught me something too, like, ‘I don’t want to be like that, for my kid.’ ”
Melanie said she apologized to Kyle for the psychiatrist’s attitude. “But I still wasn’t embracing where he was. I was still struggling and hoping it would go away. And I did that for a year.”
Kyle went public as a trans male the summer after eighth grade, when he went to sleepaway camp. As Melanie saw it, it was a test run for Kyle to try his new identity away from home. “He decided to stop waiting for me” she said. “He decided, ‘I’m just gonna do what I want to do.’ And I’m really, really proud of him for that.”
Kyle started high school that fall as a male.
Treatment for gender dysphoria
Treatment for gender dysphoria varies, depending on what individual patients need to alleviate their distress. It involves understanding and validating their emotions, and working with them to help them get relief. If they are diagnosed with anxiety or depression, those disorders are treated with therapy and/or medication.
Dealing with the gender disconnect itself can take a number of forms. As Dr. Mitrani puts it: “Let’s see what we can do to shape your responses or your coping skills or your environment to help you be who you want to be.”
Hormone therapy and surgery are options that many patients desire, but some may not. “Some want to present and be treated as their affirmed gender, but may not feel the need to go through all these steps to address the dysphoria,” he explains. “You see what their goals are and what their needs are, and you address those.”
For both the individual and the family, transitioning involves a series of decisions and challenges as they move forward. “As providers, we need to help support them through these changes,” Dr. Mitrani adds.
The families Dr. Mitrani sees are often coming to get guidance on next steps for transgender children. While holding off hormone treatment or surgery until adulthood might seem the prudent choice, to give teenagers time to make sure this is what they want, there are also reasons to act as soon as possible.
“Once you start going through puberty, the complications from any medical or surgical transitions down the road may be higher,” Dr. Mitrani explains, “and the time living with that dysphoria or that distress is longer, so the risks are higher.”
What is puberty suppression?
Hormone treatment that suppresses puberty for as long as several years is one strategy for buying time to be sure. “If you can stop puberty, then you don’t have to worry about those secondary sex characteristics — the deepening of the voice or breast development or even menstruation — and you don’t have to have that added distress of your body acting in a way that isn’t the way you feel inside” he explains. “Then, after careful assessment, if you want to move on to hormone therapy, it’s somewhat easier to get the outcome that you want.”
The typical recommended age to start hormone treatment is 16, based on best practice standards set by transgender and endocrinology organizations, but the timing, Dr. Mitrani emphasized, should always be considered based on what is best for the individual.
Kyle’s new identity
For Kyle, who is now 16, the issue is whether he is able to make the transition before he goes to college. Melanie reports that he’s started testosterone, and the family is exploring top surgery consultants. They’ve changed his name and his gender on all forms of ID, so there will be no snafus when it comes to the SATs and starting school.
Melanie acknowledges that her first impulse was to push it off. “Originally, I was like, ‘Well he’s not doing anything ‘til he’s 18, because we don’t want to change his body.’ Now, I’m like, ‘Okay, I’m wrong.’ ”
There were many painful experiences in Kyle’s first year as a transgender male, including the suicide of Kyle’s first trans friend. The family tried hard to support him, struggling at times to keep up with his expectations. “My husband took him to Radio Shack, and they got materials so Kyle could build a buzzer,” Melanie recalled. “Every time someone in the family misgendered him, he would hit the buzzer. Because he was like, ‘People, get in line.’ ”
But as the family came to accept Kyle’s new identity, it became easier on all of them. “Since we started getting onboard, he’s much better. Compared to where he used to be, before any of us knew he was transgender, he’s light years better. He’s much more at peace. He’s an awesome kid. And I couldn’t be more proud of him.”