Stanford Medicine Newsletter Updates For the Local Community

 

Young and transgender

Caring for kids making the transition

 

Illustration by Gerard DuBois

As a child, Noah Wilson thought gender meant boy or girl, the end. But when they were both 14, Noah’s best friend, Rory, came out as nonbinary, a person who feels neither squarely male nor female.

Noah — who had always assumed he was female, since that’s what it says on his birth certificate — went home and Googled “nonbinary.” (Noah and Rory are identified by pseudonyms in this story.) He was just trying to be a supportive friend but soon realized that something else was going on. The idea that people could question their gender resonated. A lot.

Maybe I’m not a girl, he remembers thinking. Worried about what his parents would think, he kept quiet and spent months wrestling internally with his gender identity.

"I was imagining scenarios where you guys kicked me out,” Noah tells his mom and dad as they sit together on their living room sofas. “It has happened to other trans kids with worse parents.”Noah, who graduated from high school in June, has been out to his parents — who have been very supportive — for almost two years. Their support puts Noah in a novel group: For the first time, a cohort of several thousand youths across the country are transitioning from male to female or female to male with the backing of their parents. This is probably good for their mental health, but even the most welcoming families face big challenges as they navigate life in the vanguard of transgender childhood. That’s why a growing group of physicians, social workers, family therapists, schoolteachers and scientists are learning how to help.

“These kids really feel they’ve been born into the wrong body, and it causes a lot of distress,” said pediatric endocrinologist Tandy Aye, MD, who founded the Pediatric and Adolescent Gender Clinic at Stanford Children’s Health in 2015. “They’ve been thinking about this for so long and trying to voice it, and often, people have been dismissive.”

Aye, an associate professor of pediatrics at the School of Medicine, first worked with transgender teens as part of her research on the effect of sex hormones on brain development. Families of her research subjects asked if she could provide medical care for their kids, so Aye began seeing patients and established the new clinic. Now one of more than 30 such programs across the country, it helps with the medical and social aspects of gender transition and connects transgender children and their families to community resources, including well-informed primary care physicians.

Weighing treatment

Dani, 16, started his transition by cutting his hair and wearing masculine clothing. He later legally changed his name and began testosterone treatment. With each step, his parents say, he grows happier and more sure of himself. Watch his story.

   

As drastic as a gender transition may seem, for children who are sure they’re in the wrong-gender body the consequences of doing nothing are worse, Aye said.

“If a child has been gender-nonconforming for a long time and is not allowed to transition, going through the wrong puberty can be psychologically devastating,” she said. Helping transgender adolescents go through the medical aspects of transition carries a different meaning for Aye than treating kids with medical illnesses. “As you treat transgender teens with hormones, you’re affirming who they are,” she said.

But early in the process, ambivalence is common, said Amy Valentine, the social worker at the Stanford Children’s Health gender clinic. She’s part of a team of about 15 clinicians who are currently serving about 50 patients.

“We want Stanford Children’s Health to be a safe haven for patients and families who are working through gender-identity issues,” said Dennis Lund, MD, chief medical officer of Lucile Packard Children’s Hospital and Stanford Children’s Health. “It’s our job to take care of patients in need.”

Before families visit the clinic, Valentine gets a comprehensive history by phone. For instance, she asks if the child has socially transitioned, which is the first step in living as their identified gender by using a gender-congruent name, switching pronouns, and changing their hair and clothing. Therapists look for three characteristics to distinguish transgender youth: They are insistent, persistent and consistent in their gender-identity expression.

Valentine wants to know how the parents interpret what’s happening, too.

“Kids really want to be understood by their parents,” she said. “They want to feel loved and accepted for who they are, and they need help from their parents to move forward. And parents come in a lot of times in disbelief, saying, ‘How did this happen all of a sudden?’”

Facing limited resources, discrimination

Today, medical support for transgender children is uneven across the country. While most urban areas now have well-established clinics, parents and children in rural locations may face long trips to access medical care and endure more prejudice in their communities.

At a minimum, all doctors should know how to have a respectful and productive initial conversation with patients who are questioning their gender identity, Aye said. For pediatricians, that means asking children what they’re feeling, what gender they identify as, and whether they have a preferred name and pronoun, she said. “Allow that conversation to begin and don’t be dismissive. Let the child express it and listen in a welcoming way.”

Transgender individuals also are likely to face discrimination. Injustice at Every Turn, the 2011 report on the findings of the National Transgender Discrimination Survey, found that of the 6,450 U.S. transgender adults who responded, 63 percent had experienced at least one serious act of discrimination.

Making the journey

Noah has been fortunate. Not only has he received good family and medical support, but his teachers and friends have also been accepting. In the fall, he will attend a college known to welcome transgender students, where he expects to be able to be open about his identity, a far cry from what earlier generations of transgender college students experienced.

After his full consultation at Stanford, he began receiving a puberty blocker, Lupron, which prevented him from going through further maturation as a female.

“If they identify really young as transgender, kids can receive a pubertal blocker as soon as any signs of puberty start,” said Aye. “If they suppress puberty and later change their minds, they can stop taking Lupron and continue to develop their own biological puberty.”For those who transition, avoiding the wrong puberty means they will look more like members of their identified gender as adults. With the medication, trans boys won’t develop breasts, for example, and trans girls won’t grow as tall or develop deep voices or facial hair.

Around age 16, transgender teens can begin receiving estrogen (for those transitioning to female) or testosterone (if they’re transitioning to male). “They get cross-sex hormones so that they’re going through one puberty and it’s appropriate,” Aye said. The patient’s levels of psychological readiness and family support are always important considerations in starting cross-sex hormones, she added.

Noah started taking testosterone in November 2016. His voice has already become deeper, which he likes. With continued use, he’ll grow a beard and develop more malelike body composition.

Support from family

Looking back on the past three years, Noah’s family has some advice for others in their shoes.

“For parents, you need to educate yourself as quickly as possible, and you need to process your own feelings away from your kid,” his mother said. Your child needs your support, no matter what worries you have along the way, she added.

“If you know that your parents are probably going to be accepting, come out sooner,” Noah said. He also found talking to a therapist to be helpful. “I felt like I had to get everything exactly figured out. And yet I definitely felt relief once everyone started calling me Noah; it was a lot better.”

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