Is it a boy or a girl? That is often the first question of new parents or parents-to-be and leads to a host of assumptions about the nature of their child. Names are chosen, gifts start arriving in pink or blue, and even the earliest parent-infant interactions show differences based on the sex of the child. But what if your young daughter starts saying she’s a boy or your son wants to be a princess? You may be at a loss of how to respond. You may wonder if you should buy your son Barbie dolls he covets or call your daughter by the new name she has chosen? What does it mean at age 3 or 4? What about at 12 or 15? Does it mean he or she will grow up to be transgender?
With the recent media blitz concerning Bruce Jenner’s transformation to Caitlyn Jenner, the public has become more informed and aware of the issues. However, to make sure we are on the same page, I want to define some basic concepts. When we talk of the sex of a person, we are referring to the biological aspects at birth of being male or female. In contrast, gender identity refers to an inner sense of being male or female and develops over time. In actuality, gender is no longer considered a simple binary concept of being male or female, but such a discussion is beyond the scope of this blog. For transgender people, their own internal gender identity does not match the sex they were assigned at birth. Sexual orientation refers to whom one is sexually attracted. And knowing a person’s gender identity does not inform you of that individual’s sexual orientation as these develop independently. For example, a transgender male to female can be attracted to males, and therefore be “straight” or be attracted to females and thus be considered “gay.” This can be a confusing concept that is often best summarized as, “Sexual orientation means who you go to bed with. Gender identity means who you go to bed as.” Gender dysphoria refers to the clinically significant distress caused when a person’s assigned sex is not the same as the gender with which they identify.
Eventually, I may receive a frantic phone call from a parent asking for help. If this call came twenty years ago, my response would have looked somewhat different from what it would look like now, as new knowledge and practices have emerged. And hopefully, we will continue to learn through research and collective clinical experiences. In the past, some mental health providers were engaged in what are now considered misguided efforts to extinguish the opposite sex behaviors and try to make the boys act like boys and the girls act like girls. It did not work and likely led to further distress. Another approach was to acknowledge the thoughts and feelings in a supportive way but teach the children how to fit in better socially in order to protect them from teasing and bullying. However, this led children to feel the need to hide their true selves and to experience deep shame.
Currently, the approach is to support gender non-conforming children in their journeys rather than trying to make them fit into a certain predetermined mold. For young children, this means allowing them freedom to explore their gender in a fluid fashion without judgment or punishment. For example, this might mean allowing a boy to dress up as a princess one week and a Ninja warrior the next. Fortunately, no permanent decisions need to be made at this stage. Current research indicates that about 80% of young children who are gender nonconforming do not become transgender adults, though a majority of them do identify as homosexual or bisexual.
However, the picture changes at puberty. If children continue to identify as the opposite gender at puberty, it is highly unlikely they will change to identify with their biological sex. A more recent medical approach offers intervention at the early signs of puberty (usually around ages 10 or 11 for girls and 11 or 12 for boys) in the form of puberty-blocking medication. By delaying puberty, or “hitting the pause button,” these children are given the gift of time to figure things out. In addition, the medication prevents the development of secondary sexual characteristics that would be difficult to reverse. For example, the medication blocks, the development of breasts, vocal chord changes, or changes in facial structure. We know that puberty is a particularly difficult time for gender dysphoric youngsters; they often dread the bodily changes that cannot easily be ignored and fly in the face of their sense of selves. There are frightening statistics showing that adolescents with gender dysphoria are at a much higher risk for depression, self-mutilation, and suicide. It is important to note that the effects of the puberty blockers are reversible. If the youngster changes his or her mind, the medication can be stopped and the individual will go through a typical puberty. However, this treatment remains somewhat controversial and is only available in limited medical settings at present.
If these youngsters continue to identify as transgender as they get older, cross sex hormones can be given, usually at age 16 so they will develop sexual characteristics of their identified gender. These changes are not reversible. And ultimately some may choose to have surgery, an option after age 18. In helping individuals and their families make these decisions throughout development, we look for consistence, persistence, and insistence of cross-gender identity.
What is the role of the psychologist? I believe one of the most crucial functions is to provide consultation with parents who are facing the challenges of raising a gender nonconforming child. Meeting alone with parents offers them the opportunity to learn about the issues, work through their own feelings, tolerate the unknown, and explore ways to best support and advocate for their child. If the child is showing signs of distress, such as anxiety, depression, behavior problems, or social problems, I would recommend he or she be seen as well. Even if such problems are not readily apparent, parents may want me to see their child to offer an opinion or want a safe place for their child to sort out feelings. In therapy, children can explore their gender identity and how they want to express it, identify stressors and challenges, and learn coping skills. If medical treatments are being considered, I may be asked to provide assessment and recommendations to the medical team, and can help the family with their decision-making process. It is a challenging road for children and their families and trained professionals are available to help them navigate it. The most important thing to remember is to reassure your child he or she has your unconditional love and support.