When do children first display evidence of gender non-conformity?

 

There is no set age where expressions of differing gender identity prove that someone is genuine. Sone parents report differences from a very early age, even before they can speak. Some children suppress their feelings, or are not sure what they mean until later in life. Some children do not have such strong gender feelings and may not express issues until they are pubertal or in their late teens.

Many children, however, experience strong gender dysphoria at the onset of puberty and with the high frequency among transgender youth of mental health challenges including anxiety, depression, social isolation, self-harm, drug and alcohol misuse, many providers view early treatment as life-saving.

Can I have caused this to happen to my child?

You cannot make someone gay and you cannot make them straight.

You cannot make someone reject the gender they were assigned at birth, not can you make them accept it.

Gender identity comes from within, it is an innate sense of feeling, present often from a very early age. It is not due to environmental or societal factors.

What are the different stages of transition?

Many children are allowed to express themselves freely in what they choose to wear, what and who they choose to play with and the activities they enjoy. Transgender children may express an intense objection to fulfilling the role of the sex they were assigned at birth and may choose to transition socially. This would include using the pronouns, names, clothes, hair style and toys that match their gender identity rather than their sex assigned at birth.

This may then extend from the family home into school, with a change of name and pronoun on the register, and a discussion with school about toilets, changing rooms, uniform, sporting activities, dormitories and school trips.

Medical intervention is not needed until puberty starts, but discussions with counsellors and doctors to make a plan should start well before puberty as a delay in treatment can lead to irreversible and unwanted body changes.

With the right medical intervention at the right time, surgical intervention can be reduced.

 

Who is qualified to treat transgender youth?

The care of transgender youth does not need to be limited to pediatric endocrinologists. General pediatricians, specialists in adolescent medicine, family medicine, medicine/pediatrics, as well as nurse practitioners, physician assistants and others are all potentially qualified to provide high quality care for transgender youth.

http://transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16.pdf

 

When should treatment start?

Transgender young children who have been free to express their gender identity in the way they feel most comfortable, are seemingly unimpaired by their gender non-conformity. However when puberty starts and is allowed to progress unimpeded, transgender youth commonly experience symptoms of depression, anxiety, social isolation, behavioral problems, school struggles, and suicidal ideation.

Early intervention with puberty blockers halt this pubertal development and while being completely reversible, allow the child to explore their teenager years without the threat of the ‘wrong’ pubertal changes.

A team of experts in the Netherlands at the Gender Identity Clinic at the VU University Medical Center in Amsterdam was the first to develop a protocol that presented the possibility of delaying, or avoiding altogether, the development of undesired secondary sex characteristics resulting from an unwanted endogenous pubertal process. This model of care includes the use of gonadotropin releasing hormone (GnRH) analogues, medications that have been used for decades to delay pubertal development in children with central precocious puberty. GnRH analogues offer a reversible intervention that allows young people temporary relief from an undesired, and potentially traumatic endogenous puberty. 

Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology. 2006;155(suppl 1):S131-S137.

Does my child need to go to CAMHS?

Mental health teams, psychologists and counsellors should not try and persuade the child to accept the sex they were assigned at birth. They should regard their role in supporting the child through their thoughts and provide a safe and welcoming space for young people to discuss and explore their gender, and any mental health challenges that may exist.

It should be complimentary to their treatment, rather than a necessary hurdle to go through in order to receive treatment.

What should the assessment process be?

While historically mental health professionals have been charged with authenticating the gender of their youngsters, this approach is rapidly falling out of favour, and is being replaced by a support model, rather than a gatekeeper model of accessing care.

Children, young people and those who support them should have space and time to explore what this all means, but should not be forced into extensive, lengthy questioning and assessment procedures which may delay access to necessary treatment programmes.

Mental health providers also play a major role in educating parents, family members, schools and others about the needs of TGNC youth, as well as advocating for the young person across multiple domains. Therapists also can work closely with parents to help them understand what their child is experiencing, and will likely need from their parents and/or caregivers. Many TGNC adolescents, like most people of any age undergoing a significant life change, will benefit from ongoing therapy during both pubertal suppression, and the first few years of gender-affirming hormone administration, and perhaps, beyond. Despite increasing visibility and acceptance, TGNC youth are likely to experience transphobia and its negative consequences, and may benefit from ongoing support. Requiring participation in therapy in order to access medical care related to physical gender transition is neither successful, nor does it promote honest communication between young people and therapists.

http://transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16.pdf

 

What baseline tests are needed?

While many centres perform baseline blood tests and bone scans, there is no evidence to suggest that these either impact on treatment protocols or influence outcomes. Financial and logistical factors sometimes make these tests unachievable and the absence of these tests should not preclude treatment.

Does my child need to be examined?

Genital examination can be very stressful for children, particularly those who have pubertal changes that are out of line with their gender identity. there should e a clear discussion about what, if any, examination findings there may be that would influence treatment decisions. Puberty can be staged by history and a clothed examination in many cases.

What are the options for therapy?

For help and support during difficult times, it is fair to say that we could all do with some counselling, psychotherapy or support at some time or another. Transgender youth may face difficulties with society, family, school, peers, education, hate crimes etc

Some children don’t have access to regular support and therapy and the use of telephone, messaging, video-conferencing are all becoming more widely used to help children and young people air and discuss their worries.

Does my child need to go to CAMHS?

Mental health teams, psychologists and counsellors should not try and persuade the child to accept the sex they were assigned at birth. They should regard their role in supporting the child through their thoughts and provide a safe and welcoming space for young people to discuss and explore their gender, and any mental health challenges that may exist.

It should be complimentary to their treatment, rather than a necessary hurdle to go through in order to receive treatment.

Should my child have blockers? Does my teen need them?

Puberty blockers should be started at the onset of puberty (Tanner 2) if the child is ready for them. This will then prevent the unwanted secondary sex characteristics from developing, thus potentially reducing any need for surgery later in life.

For teens who have already gone though some stages of puberty, the blockers are still effective in reducing any further pubertal development, and also are effective in stopping natal hormone productions allowing the gender-affirming hormones to do their work effectively and give a puberty more aligned with the gender identity.

For some, access to puberty blockers is hard – either the GP won’t help, or maybe they are just too expensive. If this is the case, hormones can be used alone with good effects.

When should cross-sex hormones be introduced?

At the time of writing, the UK protocol dictates that youths must spend at least a year on blockers before starting on hormones, regardless of age and pubertal stage.

Gender-affirming hormones should be added to GnRH analogues to assist in the development of feminizing or masculinizing features in transgender youth. While the current Endocrine Society guidelines recommend starting gender-affirming hormones at about age 16, some specialty clinics and experts now recommend the decision to initiate gender- affirming hormones be individually determined, based more on state of development rather than a specific chronological age.

Factors which support consideration of hormone initiation prior to age 16 include:

  1. Length of time on blockers – for those young people whose puberty was suppressed in the earliest stages of puberty, waiting until age 16 to add hormones means a potential 5-7 year gap, during which bone mineral density is only accruing at a pre-pubertal rate. This could potentially impact peak bone mineral density, and place youth at risk for relative osteopenia/osteoporosis.
  2. Experiencing puberty in the last years of high school or early college years presents multiple potential challenges. The emotional upheaval that occurs for young people undergoing puberty happens normally at 11 or 12 years of age. For those young people who struggle with emotional lability at that age, they do so in a relatively protected environment, regulated by parents/caregivers, and without access to potential dangers such as motor vehicles, drugs, alcohol and adult (or almost adult) peers and sexual partners. Having the physical appearance of a sexually immature 11 year old in high school can present emotional and social challenges that are amplified by gender dysphoria.
  3. Available data from the Netherlands indicates that those youth who reach adolescence with gender dysphoria are unlikely to revert to a gender identity that is congruent with their assigned sex at birth.

http://transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16.pdf

de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. The journal of sexual medicine. 2011;8(8):2276-2283.

How will my child know they are trans if they haven't gone though puberty?

there is no evidence to suggest that going through puberty is necessary in order for the child to develop the cognitive capacity acquired during adolescence and nor does it need the full myelination of the frontal lobe. Gender studies have shown that children are aware off their gender from a very early age.

What if my parents don't agree with my wish for treatment?

Although it is more beneficial for a young person to have the support of their parents or guardians, the absence of it should not preclude treatment. If a young person can show that they are competent to be involved in decision-making about their treatment, then their wishes should be taken into account when deciding on a management plan.

If one parent is supposed to treatment but now in favour, the clinician should attempt full discussion with all parties, while keeping the best interests on the young person at the forefront. The courts should be involved where necessary.

How long do I have to be on blockers for?

Being on blockers for a certain length of time should not be necessary before being allowed to start hormone treatment. There is no evidence that this is in the child’s best interests.

The GnRH analogues allow the use of lower doses of hormones to achieve masculinisation or feminisation and the Dutch model continues their use until the natural gonads are removed.

What if I can't afford blockers or my GP won't help?

For some people trying to access timely care, blockers are not possible either because they cannot afford them, or their doctor will not prescribe them. This should not mean that hormone treatment should no be available, and the hormones themselves are used to both suppress endogenous hormone production, and to masculine or feminise bodies.

When should I have surgery?

Chest binding with ‘home-made’ binders can cause serious medical complications, while even well-deserved-fitting chest binders can be tight and cause difficulties with exercise and breathing.

Having the ‘wrong’ genitals can cause great distress to young people who are at a time of life where social and relationship experimentation is taking place. We should consider at what age it may be appropriate to undertake gender surgery in line with what is best for the young person.

There are often arbitrary barriers to surgery, and artificially created age boundaries. We should try and take an individualised approach.

Where is the evidence???

Gender-affirming care for transgender youth is a young and rapidly evolving field. In the absence of solid evidence, providers often must rely on the expert opinions of innovators and thought leaders in the field.

Will they change their mind?

Discussion with transgender adults show us that these feelings have existed for many years and often have been present in some form from a very early age. It is the current thinking that children who have long-standing, persistent, insistent gender dysphoria going into puberty are extremely unlikely to ‘change their mind’.