I saw my first transgender patient four years ago. The 9-year-old child, assigned female at birth, had identified as male since age 2. His parents had taken him to different psychologists and psychiatrists and had tried to help him fit in as female. He was on antidepressant medications, having suicidal thoughts, and expressed thoughts about cutting off his breasts, which had started to develop.
When his parents did not see the improvement they sought, they decided to, in their words, "listen to what he had been saying all along." They started seeing him and treating him as a boy. They bought him male typical clothing, cut his hair and started using a boy's name and pronouns. According to his parents, the anger and depression disappeared and he was a much happier child. They felt reassured about their very difficult decision.
"We prefer to accept him as our son rather than to lose a daughter," they said. This is something I've heard from other parents of transgender children as they describe a journey of denial followed by acceptance when they realize their child needs the affirmation of their gender in order to be happy, which is the ultimate desire of any parent.
Accepting a child's
gender identity can result in challenge and controversy for a family, to be sure. But the parents I've seen have risen to those challenges, choosing to support their children in order to save them, despite the risk of rejection from family, friends and the community. Those of us who have had the profound experience of caring for these patients and their families can see that all they want is to be accepted and be happy, like everybody else.
""We prefer to accept him as our son rather than to lose a daughter."
Recent guidelines from American Psychological Association on transgender care state that "gender is a non-binary construct that allows for a range of gender identities and that a person's gender identity may not align with sex assigned at birth." The guidelines also describe "reparative or conversion" therapy as ineffective and potentially harmful. Instead, a more "trans-affirmative" care is recommended.
While rates of depression are two- to three-times higher in transgender youth as compared to non-transgender individuals, a recent study published in
Pediatrics showed that children who undergo a social transition in order to present in the gender they identify with have rates of depression comparable to non-transgender children. Other studies have shown that most of the psychiatric disorders in transgender adolescents derive from discrimination, peer rejection and lack of social support. The best predictor of positive psychological outcomes, according to research, is parental support.
It is important to point out that not all young transgender children will persist as such into adolescence, and that there might be different paths of gender development and degrees of complexity. Referral to a mental health professional with experience in this field can help guide families on difficult decisions such as undergoing a social transition.
Medical intervention before adulthood in transgender adolescents is also a matter that requires thoughtful consideration. A long-term study of 55 transgender adolescents who underwent puberty suppression followed by cross-sex hormones to induce developmental changes that match their gender identity had similar psychological outcomes in young adulthood compared to an average sample, and none regretted their decisions. This medical intervention for patients that have an adequate psychological assessment has been supported by the Pediatric Endocrine Society and the Endocrine Society since 2009.
"As pediatricians, we should support and help guide patients and families on this journey as they seek the happiness and well-being all children deserve."
In keeping with its mission to attain optimal physical, mental and social health and well-being for all children, the American Academy of Pediatrics (AAP) has a strong history of supporting Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) youth and families. In an updated 2013
policy statement, the organization urges pediatricians to ensure their offices are welcoming to sexual minority youth and stresses the importance of comprehensive, confidential psychosocial histories to identify health risks more likely to affect LGBTQ youth, as well as strengths and assets of individuals that can help buffer the negative effects of discrimination.
More recently, the academy joined with other national organizations to oppose an influx of state and local policies introduced this year that would deny transgender students access to appropriate restrooms and locker rooms and prevent them from playing on sports teams that are consistent with their gender identity. In a letter to the nation's governors, the coalition called on political leaders to reject measures that would compromise youth safety and well-being and foster harmful discrimination.
As individual pediatricians, there are several steps we can take to help families sorting through with transgender issues:
Remind parents of the importance of love and support for their child.
Encourage families to discuss and process concerns faced by transgender youth and highlight the resilience that can come from understanding, affirmation, and support.
Refer patients and families to mental health and pediatric medical professionals with experience with youth with gender dysphoria.
Educate parents on the lack of effectiveness and risks of "reparative or conversion" therapy.
Partner with youth and families as they advocate for their needs.
Nobody chooses lightly a path that leads to discrimination. As pediatricians, we should support and help guide patients and families on this journey as they seek the happiness and well-being all children deserve.
Ximena Lopez, MD, FAAP, is a member of the AAP Section on Endocrinology and the Provisional Section on Lesbian, Gay, Bisexual, Transgender Health and Wellness. She also serves as medical director for the GENder, Education and Care Interdisciplinary Support (GENECIS) program in Dallas TX, which provides mental health and endocrine care for gender non-conforming children and adolescents, and a researcher in the area of type 2 diabetes and obesity in adults and pediatrics. Dr. Lopez did her residency in Pediatrics at the University of Illinois at Chicago and her fellowship in Pediatric Endocrinology at Massachusetts General Hospital/Harvard Medical School in Boston.