Cover of Backwards Day (copyright S. Bear Bergman, 2012. Illustration by kd diamond).
Aidan Key
AS ADULTS WHO CARE FOR GENDER NONCONFORMING CHILDREN, we have enormous power to make a positive impact that will affect their lives and health. Children who are supported in exploring their gender identities from a young age learn to embrace their whole selves and develop skills to maintain self-esteem throughout their lives. It takes a village to raise a gender nonconforming child. As biological or foster parents, or other guardians of children, we can feel isolated and alone, unsure of how to approach certain topics or where to connect with others who are having similar experiences. As teachers, counselors, or other providers, we may be interested in learning more about the ways we can be helpful to children and their families. There is no right answer for every situation. Gender nonconforming children—like all children—are unique, and their needs are different. The most important task we have is to make all children feel loved and accepted for their whole selves.
There are many ways to talk about children whose gender identities and behaviors fall outside of societal norms. Gender nonconforming (GNC) is a broad term that can be used to describe children with varied interests and presentations. Some people prefer the term gender variant (GV), while others feel that the word variant implies that something is wrong with the child. There are those who use the terms gender creative, gender diverse, or gender fluid because they have positive connotations related to children being original and imaginative.
As adult trans people, many of us were gender nonconforming children growing up. This chapter provides tools and resources for those of us, including non-trans people raising gender nonconforming children, who are caring for the next generation.
Transgender is a word many adults use to describe themselves, and this term is sometimes applied to children as well. For adults, it is often used as an encompassing term to describe many forms of gender-diverse expressions and identities. However, many professionals and families use the term transgender to denote a child with a clear cross-gender identification (i.e., a child assigned male at birth who strongly and consistently identifies as female). For the sake of this chapter, we will primarily use the term transgender to describe those children with a solid cross-gender identity and the term gender nonconforming to describe those with more fluid or creative identities or means of expression.
Some families and youth programs refer to those who are assigned female at birth but identify as male as trans boys, and those who are assigned male at birth but identify as female as trans girls. Many youth centers and providers use the phrase transgender/gender nonconforming (TGNC) as an umbrella term to refer to groups of children and youth who fall into these categories.
It is often difficult to draw a line between children and youth. Puberty begins at vastly different times for different people. Cultural shifts occur in middle and high school to transform us from completely dependent to much more self-reliant. For the purposes of this book, this chapter is directed to adults caring for children up to approximately 12 years old, and the next chapter speaks to youth approximately 12 years old and up.
Many parents have an idea early on that their child is transgender or gender nonconforming based on the child’s toy and clothes preferences, playmates, or specific statements. For others, it can be a shock to hear a child say something that indicates they do not necessarily see themselves as the gender they were assigned at birth.
There is no checklist to determine a child’s gender identity. We can only do our best to put together available clues and to listen to children as closely as possible. Some gender-diverse children make statements about their gender early on, many as soon as they learn to speak. They may say things like:
• I’m not a boy, I’m a girl.
• God made a mistake. I am supposed to be a girl.
• When is my penis going to grow in?
• Why do they keep calling me a girl? I’m a boy.
• I don’t want to be a mother—I want to be a father!
If a child has articulated statements like these consistently and over a long period of time, chances are that the child has a sense that their gender identity is different from the one dictated by their sex assigned at birth.
Some families have observed certain behaviors from their children who later identify as transgender adults:
• Expressing anger at a parent for “correcting” someone who perceives the child to be a gender other than the gender assigned at birth
• Allowing or encouraging other children to believe they are a different gender
• Announcing to parents, family, and friends that they have a new name that is typically associated with another gender
• Adopting the identity of an animal such as a dog, bear, or kitten in order to have a nongendered identity and experience
These behaviors are not sole indicators of a child’s gender identity but, if observable over an extended period of time, could point to a transgender identity.
Many times, none of the aforementioned examples are evident. Some parents feel blindsided when, seemingly out of nowhere, their child announces that they are transgender and that they wish to change gender. It is not uncommon for a parent to say that there were no signs at all.
Educator/activist/poet Lee has written a chapbook about her journey of raising a queer child in a straight world, entitled, Sawing a Lady in Half.
Every mother knows. It was all there. If I was willing to see beyond my expectations and dreams. As a little girl, Ricky (not real name) always loved baseball caps and uniforms. On Halloween he always picked the Fireman, Gorilla, or Bullwinkle costume. Never the make-up, lipstick, and press-on-nails. I missed playing dress-up in those girly ways.
In second grade, the teacher asked the class to present a person from history, in costume, and the class would guess: “Who Am I?” All the girls picked famous women such as Rosa Parks, Abigail Adams, and Marie Curie. Ricky dressed as Houdini complete with top hat and white gloves. I felt this flair for male attire was telling me my child was different. He was always comfortable in loose pants and sneakers and I got used to shopping in the boy’s department.
As I write, I notice I keep writing she and then back spacing to correct. It is still hard. When the 2000 Winter Olympics aired and the Men’s Hockey players slid out on the ice, Ricky cheered, “That’s what I want to do.” Ricky mostly played with boys, suited up in full protective gear with face mask and stick. He still had his long, curly chestnut pony tail hanging out of the back of his helmet. Sitting in the chilly stands, that’s how Ricky’s dad and I knew our child from the rest of the guys.
At 15, with a girlfriend, he came out as gay and at 18 he realized his true identity was transmasculine or gender-queer. Is the journey over? I don’t know, but as a mom, I’m still looking for signposts to lead the way to his heart.
Supporting a child in a transition from one gender to another can feel like a huge decision for most adults. Many go through intense personal conflict and soul searching, but most ultimately come to a place of support and advocacy. For many of us, when facing a problem, we would like very much to be presented with an identifiable solution. While initially hard to accept, a transition appears to be such a solution. A transition from one gender to another offers a parent, therapist, or teacher a step-by-step process to “completion”—a definitive end point. This can provide comfort during an unstable time.
Books for Parents
• The Transgender Child: A Handbook for Families and Professionals by Stephanie Brill and Rachel Pepper
• Transitions of the Heart: Stories of Love, Struggle and Acceptance by Mothers of Transgender and Gender Variant Children by Rachel Pepper
• Gender Born, Gender Made: Raising Healthy Gender Non-Conforming Children by Diane Ehrensaft, PhD
• On the Couch With Dr. Angello: A Guide to Raising and Supporting Transgender Youth by Michelle Angello
• Far From the Tree: Parents, Children and the Search for Identity by Andrew Solomon
• Coming Around: Parenting Lesbian, Gay, Bisexual and Transgender Kids by Anne Dohrenwend
Books for Professionals
Treating Transgender Children and Adolescents: An Interdisciplinary Discussion by Jack Drescher and William Byne
Gender Variant Children and Transgender Adolescents, An Issue of Child and Adolescent Psychiatric Clinics of North America by Richard R. Pleak, MD
It can be even more difficult to consider that there may not be a definitive endpoint. A child’s gender may simply be a blend of genders or that child may experience a gender fluidity that changes from time to time, even day to day. It can be extremely distressing for a parent, teacher, or provider to see a variable gender expression in a child or to hear a child state that sometimes they are a boy, sometimes they are a girl, or “it just depends.”
Some important points to consider include the following:
1. Kids do the best they can with the available vocabulary. It is important to understand that binary language such as boy/girl, masculine/feminine, and pink/blue offer children restrictive words with which it may be difficult to describe the full spectrum of their experience.
2. Some children have a gender identity that is a bit of both, neither, or one in which they experience varying degrees of fluidity.
3. Gender, like life, can be a journey, not just a destination.
4. Gender does not exist in isolation. Two questions any trans person faces are “Who am I?” and then “Who am I in relation to the world?” While children may not be able to articulate this for themselves, they are certainly exploring these questions and attempting to find their best fit.
When a trans or gender nonconforming child does not make a definitive statement such as “I am really a boy,” or “I am really a girl,” it is difficult for many of us to know what to do. In some cases, parents cling to this fluidity as an indicator that the child is not really transgender. In other cases, they may ignore the child’s statements that they feel themselves to be a blend of genders, and actually press the child onward to a gender transition before they are ready or when this is not the child’s desire. Both scenarios are ways to relieve the adult’s discomfort with uncertainty.
Providing support for a child’s gender identity and exploration is not the same as insisting on a specific path from point A to point B. Pay attention to the truth a child offers and meet them there—daily, if need be. Delineate between your own discomfort, confusion, and need for certainty and the child’s need for support, encouragement, and authenticity. The latter will serve the child best in the long run.
One of the questions most commonly asked by parents, teachers, and therapists is whether gender nonconformity could be a phase. The simplest answer is yes. The only way to really determine whether a child’s interests are short term is to allow the passage of time. Whether a child, who may or may not be transgender, is going through a phase is not really the point. A nonjudgmental and supportive response to the child’s exploration is the critical component. Letting a child know that they are loved and accepted unconditionally should always be the first course of action.
Creating an environment of support will allow for healthy exploration. Supporting a child’s interests is supporting the child regardless of the outcome. Allowing a child’s musical interest through piano lessons will not necessarily make them a professional pianist. A great percentage of children experiment with gender, but only a small percentage are transgender. Supporting a child’s gender exploration will not “make” them transgender. Providing love and support simply shows the child that the things in which they have an interest are OK, normal, and part of healthy self-discovery.
Anonymous
The first time I realized that something was different about my child was when at about the age of 2, I referred to him as a boy and he said that he was a girl. I assumed that since he was so young he was confused about his gender so I corrected him. He said adamantly “no” and told me again he was a girl. I then started to observe him more closely and saw that he liked to play with dolls, wanted long hair, and sat on the bathroom seat to urinate. Since I have training in the mental health field, I immediately suspected that my child might be transgender and began to read more about this.
My initial reaction included feeling scared, alarmed, and anxious. However, this subsided as I love my child and knew that I needed to support him. I decided that I would allow my child to be who he is and let him know that he is loved unconditionally. I spoke to close family members and disclosed my child’s interests and let everyone know that I was okay with this and supporting my child. Things have not been easy for him, but he is aware of the support he has at home and this has helped him to explore his gender identity at his own pace.
Although he identifies as a girl to me, he has chosen at this time not to refer to himself as female. He has chosen a female name that he likes and I have offered to call him this in private, but he is not ready to do this yet. Part of his hesitation has to do with enduring bullying in school, but he is resilient and slowly making friends. My child is the kindest, most gentle person I know, and he inspires me to be a better person every day.
It takes a huge amount of courage, persistence, and confidence for a child to communicate their gender identification to the grown-ups around them. It is most likely that a child’s sense of their gender will remain fixed regardless of how adults respond. However, children may revise their gender label based on responses from adults.
Gender nonconforming children may change the way they express their gender identities over time for various reasons:
1. A child may identify as another gender early in life because they have not had the freedom to explore and express their gender. If a child is provided greater latitude to step outside of restrictive gender expectations, they may find their gender assigned at birth is not limiting.
2. A child may recognize the distress of others and take self-sacrificing steps to decrease or eliminate that distress even at their own expense. If a child feels that their parent will not love them, or that their parents might divorce over the issue, they may be scared enough to minimize the importance of their own needs.
3. Some transgender children have experienced daily bullying and violence and can see no other way to make it stop except to “go back.” Others find that they are isolated or rejected by their peers at school or within their neighborhood and understand that, if they compromise their own identity, they may regain some of that acceptance and inclusion they so deeply desire.
4. Children who feel themselves to be more fluid in their gender identity may find difficulty “landing” on a single gender. Our current options of either “male” or “female” may feel inadequate or limiting. If a parent or therapist does not recognize a child’s gender-fluid identity and a child is restricted by only two options, that child may feel like they have no choice but to “settle” for one over the other, finding neither one to be a perfect fit.
Kevin R. is the proud and loving father of a daughter who he erroneously thought was his son.
My wife is from a family where most of the children were girls. What a surprise when, at the ultrasound appointment, our doctor presented us with a picture labeled “boy parts.” Our wonderful child was cerebral, passionate about reading, video games, and Pokemon, and always had friends of both genders. But, as a young teen and just beginning puberty, our son began having morning bouts of depression and anxiety. We sought out a child psychologist who, after several sessions, mentioned to us that kids at this age can start having issues over sexual identity. She asked, “Has your child ever mentioned being gay?”
A short while later, our son and his girlfriend came home from a shopping trip. He’d bought a girl’s short cropped jacket that was way too small. I refused to let him wear it! We had a huge power struggle. Victorious, I ended up taking the jacket back to the store. A few nights later, I was lying in bed and my son came in to talk to me. He said, “I need to start wearing some girl clothes. I think that will make me feel better.” We then had what I recall being a very surreal discussion, in which my son told me he thought he was a girl. We hugged. S/he left the room. I then did the only appropriate thing a father would do in a situation like this: I had a panic attack.
Apparently the ultrasound, and its label “boy parts,” was wrong. Over the next year and a half, our child transitioned. She grew her hair long and, for school, dressed in girl tops, baggy cargo shorts, and silver flip-flops. All the while, she continued to hang out with her same friends—a group of nerdy guys who were deeply into video games. While I was prepared for her to fully transition sometime after college at, say, age 25, she had a different idea. She invited a number of her friends over for a party. The invitation read, “Let’s celebrate! I am a chick now.” The next few weeks felt like a whirlwind of preparation, including a name change and a discussion with her school. On her first official day of school as a girl, I dropped off one very scared kid in a short-cut sundress. The whole day, I was anxiously glued to my phone, ready to pick her up at a moment’s notice. I already had plans for changing schools, if need be. Everything went fine.
We have a very well-adjusted daughter who has lots of friends and is doing great in school. She and her little sister are best friends. In fact, her sister rolls her eyes at us and says, “So, she used to be a guy and now she’s a girl, and what’s the big deal? She’s still the same person.” It was a rough ride for me. As a lifelong GLBT supporter, it turns out that it is a lot easier to be accepting when it is someone else’s problem. Joining a support group and meeting other parents and other trans kids was critical for me in making it through this. I used to think it might be the end of the world, but I now see this as a life-changing positive experience. Who doesn’t want their child to be happy and to become the person they are really meant to be?
The first question on many parents’ minds is whether a gender nonconforming child will grow up to identify as transgender. In some cases, adults also wonder whether the child will identify as gay, lesbian, or bisexual. Outdated research has indicated that, for most children, a cross-gender identification disappears over time. In this research, however, there is usually no distinction made between a child’s gender identity (who they say they are) and gender expression (what they prefer to wear and toys they like to play with). In other words, the children in these studies may have been challenging gender norms but may never have identified outside of their assigned gender. In these cases, the children did not have anything to “grow out of.”
Gender nonconforming children grow up to identify their sexual orientation as lesbian, gay, bisexual, heterosexual, queer, asexual and so on. If they do identify as transgender as adults, there are many ways in which they might understand their gender identity, including as trans men or trans women, or as genderqueer, identifying with neither gender or both genders.
As those caring for gender nonconforming children, we have a strong desire to know exactly how they will identify as adults. However, in many cases there are too many variables to accurately predict how children will later see themselves. The best we can do is to be respectful, loving, and nonjudgmental, creating safe environments for children to use their most truthful voices.
Many parents ask themselves, “Have I somehow caused this?” A father may wonder whether he spent enough time with his son, and whether this affected his son’s identification as a girl. Some parents wonder whether factors in pregnancy led to their child’s gender nonconformity. Others feel guilty that they wished for a boy during pregnancy and that somehow they transferred that desire to their daughter, who ultimately decided to become a boy. Some parents blame themselves for parenting styles they believe led to their child’s gender nonconformity.
The search for an answer is natural, but it can also be quite damaging. It can cause rifts between parents and cause parents extreme amounts of guilt and shame. While we do have some basic theories about gender identity development (explored in Chapter 6), no developmental theory has shown conclusively that any particular genetic, hormonal, or social influences lead to gender nonconformity. Parenting style has not been linked to later transgender identity. As far as we know, there is nothing we can do to influence our children’s gender identities or sexual orientations. We cannot change whether they will be LGBTQ, but we can change how they will be LGBTQ—whether they will be proud of themselves, take care of their health and well-being, and retain close connections with their families.
It is critical to make the distinction that sexuality—or to whom one is attracted—is different from gender identity—one’s innate sense of their gender. While some boys with a more feminine nature or girls who are more masculine may grow up to have same-sex attractions, a child’s gender identity is not the same as their sexual orientation. The reality is often that peers and even adults interacting with children conflate concepts of gender and sexuality. Peers may ridicule children for being “gay,” but their teasing is often based on gender expression.
The difference between gender identity and sexual orientation is important to think about in relation to children for a number of reasons. Assuming that a child is dealing only with an issue of sexuality when it is their gender they are exploring can result in an adult caretaker missing a chance to connect with the child and support them. The best stance is always to be open and affirming of any gender expression that children seem to be exploring.
Talking about gender with children is different than talking about sexuality. Conversations about gender are appropriate for children of all ages. For the most part, issues of sexuality can be saved for the beginning of adolescence, but there are many nonsexual ways to talk with children of all ages about attraction. We can talk with children about same-sex and different-sex couples, and explain that some men love other men or women love other women, laying the groundwork for healthy conceptions of both gender and sexuality.
Some adults working or living with gender nonconforming children are confused when a child discloses a gender identity and sexuality that do not seem to “match.” For example, a young person assigned male at birth may announce an attraction to women and a gender identity as a woman. This child’s caretakers may have assumed that no matter the child’s gender identity, the child would arrive at a heterosexual orientation, when the truth is that transgender people can have any sexual orientation.
Dallas Denny and Jamison Green
Nancy Silverrod of the San Francisco Public Library has compiled an annotated bibliography of children’s books dealing with gender transgression in all its forms. She points to Munro Leaf’s 1936 Ferdinand the Bull as perhaps the first book for children that shows a character refusing to conform to gender norms. Ferdinand is expected to participate in bullfights, but he prefers to smell flowers. Two other early children’s books identified by Silverrod are Charlotte Zolotow’s 1972 William’s Doll and Tomie de Paola’s 1979 Oliver Button Is a Sissy. In all three instances, the conflict is resolved normatively. Ferdinand becomes properly bull-like when he is stung by a bee; William’s grandmother tells his father he requires exposure to a doll so he can learn to be a good father; and Oliver’s tap dancing is OK’ed because “his father reluctantly decides it is a ‘form of exercise.’”
Silverrod contrasts the aforementioned books with Harvey Fierstein’s 2002 celebratory The Sissy Duckling, which ends when Elmer the Sissy Duckling’s father accepts him. Before Fierstein, Ron Pejril, in his 1989 Fluff the Bunny, used a nonhuman character to explore gender transgression. Fluff is attracted to both pink (for girls) and blue (for boys). Expected to be blue, and losing friends because he can’t bring himself to be only blue, Fluff goes into his closet to wear pink things and listen to pink songs. He eventually blends pink and blue and comes to accept himself as purple.
In this century, a new category of young adult books has arisen in which the protagonists are transgendered or transsexual or just ungendered. As examples, Silverrod lists Anne Peters’s 2004 Luna, Ellen Wittlinger’s 2007 Parrotfish, and Carol Plum-Ucci’s 2002 What Happened to Lani Garver. A growing number of books about and for children—some authored by parents with trans kids—celebrate trans children, calling for the rights of children to express their gender without interference. These include Marcus Ewart’s 2008 10, 000 Dresses and Cheryl Kilodavis’s 2010 My Princess Boy.
Many young trans people have found inspiration in manga like Takahashi Rumiko’s Ranma ½, in American comic books (Superman’s pal Jimmy Olsen had a real penchant for dressing up!), and in the magazines and books of science fiction and fantasy. Prior to the 1990s, material was scarce and hard to find, but trans people have always been skilled at ferreting out information—and sometimes they come across something memorable quite by happenstance. At age 13 one of us (Denny) chanced upon L. Frank Baum’s The Marvelous Land of Oz in the Pack Library in Asheville, North Carolina. In this 1904 book of children’s fiction, the boy Tip turns out to be none other than an enchanted Princess Ozma of Oz.
The ways in which children understand the concept of gender are closely linked to their age and developmental level as well as their exposure to information. As children, teens, and then as adults, we have learned many things about the world, including our current framework of gender. To understand the world in the same ways we do, children must learn these same concepts. For example, we, as adults, see (for the most part) two genders in the world. We then equate the genders of male and female with particular body parts. We also understand that (without hormones or surgeries) our bodies will remain the same with respect to those body parts. We then know that people have certain expectations placed on them because they have either “male” parts or “female” parts. Children do not come into the world knowing these things. See Chapter 6 for an exploration of how children at different ages understand gender.
A three-year-old child, assigned male at birth, would likely have difficulty understanding why he could not be a mother when he grows up. Some professionals tasked with assessing a child’s gender identity will draw a distinction between a child who says, “I am a girl” and a child who says, “I wish I were a girl” with the former being a child with an identity issue (transgender girl) and the latter being a child who simply has feminine interests (gender nonconforming boy). However, consider that it might be much easier for a child who is four years old to say, “I am a girl” than it is for a ten-year-old. The more developmentally mature ten-year-old has had considerably more time to learn about gender, society, and the perceived limitations of their own physical body. The ten-year-old may have already lost considerable hope about ever being a girl and, in a resigned way, articulate their wish instead.
Some children may not have the language or the ability to articulate their distress regarding their gender. They may have at one point tried to communicate their thoughts but were dismissed or reprimanded, and thus discouraged from attempting any further discussion. There may have been one time a child said, “I wish I were a boy” and a well-meaning adult may have responded by saying, “Oh honey, it’s so wonderful that you are a girl! You can do anything that boys can do.” Even a “positive” message like that can be silencing and invalidating to a young child trying to articulate their internal feelings.
Many adults are hesitant to discuss gender diversity with children because they believe that it may cause or encourage them to become transgender. The truth is that a child’s gender differences exist whether they are discussed openly or silently avoided. There is no evidence that anything we say to children increases their likelihood of being lesbian, gay, bisexual, or transgender as adults.
Books for Young Children Exploring Gender
• 10, 000 Dresses by Marcus Ewert
• The Adventures of Tulip, Birthday Wish Fairy by S. Bear Bergman
• Backwards Day by S. Bear Bergman
• Be Who You Are by Jennifer Carr
• A Boy in a Bikini by Russell Frank
• A Different Kind of Life by Katie Leone
• My Princess Boy by Cheryl Kilodavis
Cover of Backwards Day (copyright S. Bear Bergman, 2012. Illustration by kd diamond).
Identity exploration is a natural part of childhood. This includes exploring bodies, language, clothing, games, and music. An exploration in clothing choices, where a child seemingly “crosses” gender lines, may not be about that child’s gender identity. It might simply have to do with the child’s color preferences or a tactile interest in fabric textures. Some children are very imaginative, while others are physically active; some are emotionally expressive, while others are introverted. These are not characteristics of gender but are qualities of being human. Exploring identity and how to express that identity is a natural part of the healthy development of any child. Gender expression is simply one aspect of that exploration.
Toys, colors, clothing, hairstyles, and activities do not have a gender of their own. They are given a gender designation by our society. A girl may have a preference for pants and a boy may enjoy wearing a dress. Neither outfit will “make” a child desire to change their gender. For a child, what is confusing are the arbitrary societal rules assigning gender to nongendered items.
Movies About Gender Nonconforming Children
The film Ma Vie on Rose (1997), directed by Alain Berliner, tells the story of a young boy named Ludovic, who dreams of growing up to be a woman. In the movie Tomboy (2011), directed by Celine Sciamma, young Laure moves to a new neighborhood and introduces herself to the town children as a boy.
“My dad said that boys don’t belong in the kitchen. That makes me sad because I really love to cook with my grandma. She’s sad, too.” —nine-year-old boy (Classroom training led by Aidan Key)
Cooking will not make a boy gay or transgender. Teasing him, belittling his interests, or preventing him from engaging in this activity will only show him that something he loves is somehow wrong, or that there is something wrong with him for wanting to do it. The reality is that children can learn to conform to society’s rigid gendered expectations. No child wants to give up the toys, activities, or clothes they love—they simply recognize that life will be harder if they do not. Rejection by peers and disappointment or anger from parents inspire powerful motivation to conform. Children may simply give up as their words are either ignored or are dismissed as impossible. The price tag of this conformity is high and can be devastating.
Emotions do not belong to one gender over another. Our society values toughness and resiliency in boys, but these qualities are beneficial for girls as well. Sensitivity to others is encouraged in girls, but boys need to learn this, too. These emotions and qualities are attributes of a well-balanced child. For a child to develop strong mental health, it is important to allow that child to experience the full array of emotional expression.
Children (Elenore Toczynski).
It is important to talk with other adults and children who are part of your child’s life about the accepting and affirming environment you are striving to create. Colors, toys, activities, and friends should not have restrictive parameters assigned to them based on gender. Disparaging comments or actions toward a child, based on archaic gender norms, should not be tolerated. Wherever possible, make sure that any environments your child enters (such as schools, camps, or after-school programs) have inclusive policies and an antibullying commitment.
“I see my daughter’s transition as one of the biggest gifts of my life. I see her as heroic, and only wish we could have helped her transition when she was 6 and spared her all the years of pain and secrecy.”*
The Maines family.
Wayne is opening up a new dialogue aimed at addressing transgender children, fatherhood, family, school culture, and civil rights. His blue-collar roots, industrial background, and leadership abilities have prepared him well to relate concepts of diversity and transgender issues.
I never thought I would become an activist for any cause. I am a conservative man. I am a proud military veteran, hunter, and sports fan. But when you love someone, you do things beyond the norm. Until a few years ago, I had an average family. I had identical twins. They were born boys, but I would soon learn that I had a daughter.
When Nicole first expressed her feelings to me, I had trouble sharing my emotions and having the courage to tell the world about my daughter. When I finally accepted her, I thought that the world would too. In the fifth grade she put on a new dress and proudly attended school as Nicole. Her classmates said it was about time, but adults did not respond the same way. A grandfather, the Maine Christian Civic League, and the children who followed them placed my daughter in harm’s way. One day early that school year a male student followed Nicole into the bathroom and said, “My grandfather says we do not have to have any faggots in our school. If you can use the girl’s bathroom, so can I.” From that point on Nicole faced bullying, harassment, and discrimination.
I was angry, disappointed, and frustrated that people feared the unknown. But there also seemed to be people who stood by us—people like Dr. Norman Spack at the Boston Children’s Hospital, who helped develop a plan for Nicole to grow and prosper; our friends at Gay and Lesbian Advocates and Defenders (GLAD), who are helping us protect her civil rights; and the Transgender Equality Youth Foundation in Portland, Maine, which has supported us every step of the way.
We thought the school would do the right things to protect our children. When they didn’t, I found myself talking to people at the end of our driveway, at sporting events, and at school. This approach was not enough. Nicole continued to suffer and we thought we had failed her. No matter how hard we tried, the school would not allow her to use the girls’ bathroom and Nicole continued to be separated from her classmates, every day reinforcing that she was different from her peers.
With our backs to the wall, we submitted a Maine Human Rights Commission complaint—and we have been on an emotional roller coaster ride ever since. One afternoon we learned that conservatives in Maine wanted to roll back transgender rights protections through a bill called LD1046. After much discussion, we agreed the stakes were too high and that failure was not an option—and we let our 12-year-old daughter join the public fight. The time Nicole spent at the state capital lobbying to defeat LD 1046 was a turning point for me. Speaking out gave Nicole a voice. I watched her begin to heal in the hallways of our State House. Throughout our legal battles, the negative press, and the legislative challenges, our children have been brave and suffered dearly. They had to leave their friends, had to live in hiding, and lost their love for school. But my children are stronger and more confident for having the chance to be heard.
The need for courage is sometimes forced upon you. When my daughter was placed in harm’s way, I knew I had to do something. I find myself being described as an LGBT activist, but I see myself as a dad just trying to protect his children.
Parents can experience a high degree of mixed emotions in relation to their children’s gender differences. In families with two parents, one parent may experience hope and optimism, while the other parent is resistant, only to find that they switch experiences later on. Seeking out parent support groups or individual or family therapy can be extremely valuable in learning how to work together as a family to acknowledge everyone’s needs.
The Family Acceptance Project, directed by Caitlin Ryan at the Marian Wright Edelman Institute at San Francisco State University, includes significant research on families of LGBTQ youth. One of the most important findings in their studies is that family acceptance of LGBTQ youth protects against depression, suicide, and substance abuse, and improves health and self-esteem. Many parents inherently know this, and many with teens or young adults wish that they had provided a more accepting environment for their children early on.
Conflicting feelings can be readily present even within a willing, supportive parent. It is not easy, especially at the beginning, to support and advocate for a gender nonconforming child. It is quite common for parents, even as they seek support for their child, to have mixed feelings and experience internal resistance. Parents frequently say things like this to themselves and each other:
• I didn’t sign up for this!
• You’re always letting her get away with stuff. Now look what happened!
• You’re too hard on him. I wish you’d lighten up!
• I wish my child were “just gay.”
• I’m a shy person; I can’t even stick up for myself. How am I supposed to do this for my child?
• I hate to say this, but I wish my kid had diabetes or something. At least people know what that is!
• At first, I didn’t want to be seen with my child. I felt like everyone was looking and judging. I was embarrassed.
Parents of gender nonconforming kids come from all walks of life—liberal and conservative, religious and agnostic—from all class backgrounds, and all ethnicities. Expectations of gender and gender roles are intrinsic to these other aspects of identity, and it is rare to find parents who do not need to reexamine their own hearts and minds as they move into acceptance and support of their child.
Rarely will you encounter a family that, at least initially, considers it a blessing to have a gender nonconforming child. Part of being a good parent is keeping your child fed, warm, and safe from harm. While attitudes are changing, transgender people have historically experienced ridicule, ostracism, contempt, and violence. What parent wants to support their child’s innate gender identity and expression when the repercussions of this “acceptance” can lead to such a marginalized life? It is no wonder that many parents, teachers, therapists, and others who are caring for these children are fearful.
Denying the presence of a gender identity issue is quite common. Many parents point to their child’s level of femininity or masculinity as proof that their child is not really gender nonconforming. For example, if their child is active in Boy Scouts, on the basketball team, and has a girlfriend, they may insist that it is impossible for their child to be a girl. This parent has made the mistake of equating their child’s gender expression with their gender identity. Of course, a child can like the Scouts (embrace group activities), play basketball (enjoy team sports), and like girls (have a lesbian orientation). Another form of denial can include hanging tightly to the belief that a child is going through a “phase.”
Very common explanations for children’s behaviors include the following:
• She’ll do anything for attention!
• He’s very dramatic and will do anything simply for the shock value.
• This is just one more thing in a long list of things he’s done to drive us crazy!
• This gender stuff isn’t her issue—she is easily influenced by friends and always dives into new things without thought.
Coming to terms with a child’s identity can be heartbreaking for some parents and much easier for others. It is safe to assume that most parents want what is best for their children—to see them happy and to keep them safe. It takes a caring, brave parent to embrace and support a child when the fear of societal judgment and stigmatization can be so high.
Those who champion the cause of a child they know and love may be quite surprised to discover they have deep feelings of grief. On one hand, they recognize the value of support and may even see immediate improvements in both temperament and self-esteem of the child. On the other hand, this was a child they loved—deeply—for exactly who they perceived them to be. Many assume that the child will have no chance to be in a loving relationship, have a satisfying career, or a family of their own. Despite the living, breathing presence of their child, the loss is present and is important to acknowledge. Moving through grief allows for a person’s sense of loss, and it also makes room for the rediscovery of hopes and dreams.
While everyone’s experience is different, there can be an even deeper sense of grief for parents whose children are older. This may simply be because they have had a greater number of years raising their child, cultivating those ideas of grandchildren and someone to love their child. Switching names and pronouns, not to mention discarding any gender-influenced hopes and dreams for that child, is very painful. Additionally, older children may make demands like removing family photos from the walls or any other “evidence” of the gender that caused them so much anguish. It is not an exaggeration to say that, for some parents and other family members, it can feel like a death in the family.
Francesca Terry is an elementary school teacher and the mother of three vibrant boys, the oldest of whom transitioned at age five.
My daughter socially transitioned into my son when he was five years old. This was done against the advice of “specialists” at the local children’s hospital, based on my strong gut instinct and validated by members of Gender Diversity’s parent support groups. I remember the day I finally got it—what he’d been trying to tell me since he was three—that he was a boy. That day was intensely bittersweet because, while relieved to finally have the “reason” for his angry and chaotic behavior, I was secretly devastated to lose my daughter.
When a child transitions, some have likened it to a death in the family. But, unlike the actual death of a child, we as parents of a transgendered child have to defend, advocate for, protect, and educate despite the grief we feel inside. We don’t experience the empathy and understanding that, in another situation, would be immediately offered to alleviate the pain we feel inside and really need. Many days I hid my grief behind a veneer of confidence and acceptance.
For me, the grief felt shameful and was isolating. The few people in whom I did confide told me how lucky I was to have a child at all, or said how wonderful I was for accepting my child and doing the right thing. I realize now that I was grieving not the actual loss of my daughter but the idea of my daughter. I still wanted the hopes and dreams I had for her when she was born, you know—mother/daughter stuff: the prom dress, mani-pedi spa trips. This is where the shame set in—that grieving my daughter was wrong because I had a healthy happy son. I felt isolated from other parents of transgender children in my support group. They weren’t voicing this grief.
Two years after he transitioned, I had nothing left to advocate. We had pared down our family and friends to only those who unconditionally supported us. The school and doctors were on board and life was settling down. I had been successful managing the “logical” parts of the transition. I could finally focus on me, but I had yet to address my hurting heart. I was an angry, sad, confused mess inside. I started confiding my guilty secret to a few other parents at the support group, and realized that they too were struggling with similar emotions! Here we were sitting in the same room with the same suffocating feelings, but no one was saying a word. When I opened up about my own feelings, it was almost as if we all finally had permission to talk about our grief. It was transformative to speak honestly, one parent to another. Acknowledging the grief—knowing we all felt the same way—allowed the logical part of my brain to meld with the feelings in my heart. I began to truly heal.
In a culture that has not provided gender options beyond “male” and “female” and operates on the assumption that anatomy equals gender, most adults raising children take this for granted. Many parents feel guilty about not seeing their child’s gender nonconformity earlier, and many judge themselves for not listening to their child earlier.
“My 5-year-old trans daughter is struggling with the fact that people keep telling her that she ‘used to be a boy.’ Her response is anger and frustration, and she says, ‘No, I was ALWAYS a girl.’ When I tried talking with her about this, explaining that we had ‘made a mistake’ when we assumed she was a boy, she got really angry. I realized how hard it is for her that we didn’t understand earlier that she wasn’t a boy. I told her that it was OK to be angry and apologized that I had been mistaken in her gender. She is obviously having a hard time with this, and clearly feeling betrayed and frustrated. I don’t see how I could have known sooner, but really, should I have been able to see this? She certainly thinks so and the pain and hurt in her eyes is hard to see. I am feeling so guilty. It breaks my heart that I have unwittingly hurt her.”
Not every parent will experience all the emotions expressed here. There are as many ways for a parent to experience a child’s gender nonconformity as there are parents. Feelings sometimes considered negative are an important part of a parent’s process of acceptance. Parents and other family members often need time and space to express denial, anger, grief, and fear before they are able to step into acceptance, support and even advocacy for their children. A parent can be fully supportive while deeply wishing their child’s gender “issues” would just disappear.
Increased distress experienced by a gender nonconforming child is often what propels an adult to finally seek outside help. Pressure from peers, parental or teacher reprimands for gender-atypical behavior, reproachful looks and disapproving comments are occurrences that are readily perceived by a trans child and subsequently internalized. This can result in angry outbursts, elevated frustrations, increased anxiety, depression, withdrawal, violent behavior, and threats or actual self-harm. For many adults, this distressing behavior from a child can launch them from a place of resistance to one of acceptance (sometimes it starts as resignation). The bottom line is that we do not want to see our children in pain. Not all parents are resistant—some may have viewed their child’s presentation as a phase, while others did not see it coming. Regardless, it is necessary to become willing to take the next step—accept the child as they are and identify the ways in which they need support.
As parents roll up their sleeves to learn more and get past the early confusion and fear, they quite often come to a place of delight and gratitude for the positive changes in their child’s life as well as their own. While agreeing that it is challenging, and sometimes painful, many parents ultimately declare they would not have had it any other way. They recognize their child as an amazing and beautiful gift—someone who teaches them about bravery, authenticity, and acceptance. Many name their child as the hero in their lives.
“If you had told me a year ago that I would be the proud parent of a trans boy, I would have told you you were crazy! Now I can honestly say that it’s the best thing that ever happened to me!”—Father of a 10-year-old trans boy at a Gender Diversity Parent Support Group
Carolyn MacGregor is a freelance editor who lives with her two daughters in Seattle, Washington, and has been active on the planning committee for the Gender Odyssey and Gender Odyssey Family Conferences since 2011.
My gender journey with my oldest child began the moment Ian was born, or perhaps even conceived, but it wasn’t until he asked for a dress at the age of four that I really started to notice. Yes, there were signs—his preference for female playmates, his choice of female characters in role play, his interest in nail polish and “pretty” colors and clothes—but I attributed that to my parenting style; I bought bright-colored clothes for him, dolls and trucks, didn’t cut his hair very short, and tried to avoid gender stereotyping. After several requests, I bought Ian a few skirts and dresses for Ian at Goodwill, thinking he intended them for play, but the moment we returned home he changed into them and headed out the door to play at the park. After that, the dresses joined his existing wardrobe, he asked to grow his hair long, and as he outgrew his “boy” clothes, we replaced them with “girl” apparel. Yet, all this time, Ian played happily with trucks and trains, was fascinated by construction vehicles, and enjoyed building things. Ian was Ian—a boy who liked girl things, and boy things, too. Before long, strangers started to identify Ian as a girl—a tomboyish girl but a girl nonetheless.
And so began the next five years of our journey; effectively, Ian lived as “she” but went by “he,” for the most part quite assuredly. During this period of time, he would occasionally comment to me: “I wish I was a girl; it would just be easier.” Would it have been easier for me? Undoubtedly! My job as the parent was to walk ahead and clear the obstacles from his path, so to speak. I talked with the schools, the camps, the babysitters, other parents, ensuring that anyone who might have any influence or authority over him would be respectful of his choices and my decision to support him.
At nine years old, Ian entered a head-heart process of several months during which he worked over the dilemma constantly. There might as well have been steam coming out of his ears, as he turned the question over and over—who am I? Boy or girl? Some percentage of each? Somewhere in the middle? Somewhere between the middle and girl? As I would tuck him in each night, he would present his current findings in a fraction or percentage split. And then it happened—one night he said to me: “Mom, I want to transition. Boy just isn’t working anymore.” And with that, she became Zoë. . . at home, school, and everywhere in between. But here’s the rub—Zoë didn’t change, her name and pronoun did, and, as one might expect, the way the world responds to her has changed as well. And yes, it does seem easier. At eleven, Zoë loves who she feels herself to be. But we both smile as we look at the adorable baby in the old photos, and the toddler in boy clothes, because that is who she was. In every moment, she was never asked to be anyone other than herself. The pride she has in her identity is fierce and I wouldn’t have it any other way.
It can be difficult to set clear boundaries and expectations for a child while working through the many different emotions a parent or guardian experiences. It is important to recognize that consistent, strong parenting, on all issues (gender related or otherwise) provides children with feelings of security and safety.
Ideas for maintaining consistent parenting in gender-related areas:
1. Do not use gender-related care as a reward for good behavior or as punishment for bad behavior. Acknowledgement, support, and transition-related care are not items to dangle in front of a child in order to encourage good behavior, nor are they things to withdraw in the case of bad behavior. A parent would not withhold medical or mental health treatment if a child brought home bad grades. Gender-related care should be no different.
2. Do not use your child as the sounding board for your distress, grief, anger, or confusion. Parents can have a hard time navigating their feelings regarding their child’s gender identity or expression. This can be compounded by the fact that so many have to navigate their feelings in isolation. The lack of societal understanding, difficulty finding an experienced therapist, spousal conflicts, and loss of friendships and other bases of support can leave a parent with only one outlet for their feelings—their child. This is not the appropriate outlet. Children can and do internalize the challenging feelings expressed by their parents and feel guilty, responsible, shameful, anxious, and confused. A parent should find an adult with whom they can address their feelings. Keep looking until you find a supportive, caring person who can help you look after your own heavy heart, but do not burden your child with it.
3. When confused about what to do, take gender out of the equation. Because the “gender issue” can take center stage in a family’s life, and sometimes for a lengthy period of time, it is easy for a parent, teacher, or therapist to assume gender is a factor in situations where it may not be. This can result in overexplaining, defensiveness when none is needed, and an inability to see solutions to problems. One way to address a situation where the solution is not clear is to frame a scenario where the gender component is removed. Imagine if the child of a friend were in a similar situation. What advice would you give to that parent? Replace the gender piece with another aspect of identity. Does that help develop a better perspective or solution?
Parents and experts agree that having a consistent parenting approach to a child’s upbringing is ideal. Parenting a gender nonconforming child is no exception. In the past, some gender experts said that insisting that a child conform to societal gendered expectations was the best way to keep them safe. Now experts are saying that the best way to keep children safe is to support a child’s gender identity, develop their self-esteem and resiliency, and ultimately change society. It will come as no surprise that this less-than-definitive messaging from the professional world can serve to put parents at odds with each other. The question for parents ultimately comes to this: How do we keep our child safe today while we work to change the world around them?
Parenting is often divided into two basic roles. In families with two parents, one parent sometimes serves as nurturer and protector, while the other takes on the role of pragmatist and disciplinarian. In families with one parent or where parents have similar personality structures, these roles can occur within one person.
The nurturing part of a parent views the child as the center of the universe, while the pragmatic side of the parent focuses on the child’s role as a member of a family, student within a school, and ultimately a member of society. Normally, these parental roles can be reasonable and complimentary. The nurturing side of a parent may lead them to be a frontline supporter of a gender nonconforming child, ready to buy the preferred gender clothing, accommodate hair length requests, do online research, read relevant books, and more quickly adopt name and pronoun changes. The pragmatic side of a parent may appear more resistant to allowing and supporting a child’s gender preferences because their role is to protect their child. It can be difficult to imagine the hardships a child may encounter at school, within a neighborhood, or in relation to extended family, making a parent resistant to actions of support that feel too permissive, impractical, and potentially dangerous to a child’s safety.
Following are some considerations for parents who are coming into conflict with themselves or each other about parenting styles:
1. If at all possible, it can be helpful to utilize a counselor skilled in negotiating parental conflict as well as one who is familiar with gender-diverse children.
2. Approach differences of opinion with mutual knowledge that each parent comes from the same foundation of wanting what is best for their child.
3. Recognize that each parent may have their own timeline for understanding all the issues, navigating personal barriers, and making determinations on the best course of action for their child. For example, one parent may need to move faster than they would like while the other could consider slowing their pace, ideally allowing everyone the ability to move forward as a family.
4. Consideration for the child’s distress may trump any timetable or course of action that the parents decide. If you have a child considering self-harm, waste no time getting professional help and put the needs of your child first and foremost.
5. If your child has consistently asserted their gender presentation over time, do not try and convince the other parent (or yourself) that your child is going through a phase. Days, weeks, and even a few months may constitute a phase. A year or more is significant and should not be dismissed.
6. Do not leave the information seeking or knowledge gathering to one parent alone. Reading a book about transgender children does not make your child transgender, nor does consulting with a knowledgeable professional. If one parent has more knowledge on the issue than the other, it can create an even wider chasm when important decisions need to be made.
7. For parents who are divorced or separated, it is extremely wise to set aside relationship differences as much as possible. Bringing a child’s gender issues into a courtroom can serve to prolong the proceedings as courts seek to educate themselves on what may be a very unfamiliar topic. Court cases can go on for years. The increased expense could be greater than a child’s entire college education. The resulting damage to the child could permanently affect them and destroy their relationship with one or both parents. For parents involved in legal battles over custody and care for gender nonconforming children, it is important to seek out legal advice from someone knowledgeable about gender issues.
One of the first steps that many parents take when realizing their child is gender nonconforming is to search for others who are grappling with the same issues or service providers who have experience working with gender nonconforming children. It can be lonely and isolating to face these issues on our own, and many people make wonderful connections that enhance their ability to be the best caretakers possible.
There are several organizations that provide support for families through in-person groups for both parents and children. Ideally, a parent group occurs at the same time and place, in a separate room, from the children’s group. Some children’s groups have volunteers who engage children in imaginative play while guardians have time to express their fears, frustrations, and triumphs to understanding ears. Other parent groups have email lists and chat rooms that provide online connections for those who live far away from in-person groups. As children grow older, there are also online resources for them. In addition, annual conferences provide places for parents to connect with each other and for children to meet and play with other gender nonconforming children.
Parent Support Groups
• Gender Diversity: genderdiversity.org
• Transforming Family: transformingfamily.org
• Trans Youth and Family Allies: imatyfa.org
• Gender Spectrum: genderspectrum.org
• TransActive: transactiveonline.org
There are providers such as pediatricians, child psychiatrists and psychologists, and family therapists who have experience working with gender nonconforming children and their families. These people can be great resources in thinking about the many factors contributing to an individual child’s identity. Establishing relationships with providers early on can also be important as a child approaches the age at which some families begin to think about possible medical intervention related to gender. Families that do not have established relationships with providers before this stage may end up in more of a rush to connect with providers as puberty approaches.
For many families raising a gender nonconforming child, the distress experienced by that child, coupled with societal challenges, can become a focal issue within that family. By the time a family seeks (or manages to find) any outside support, the urgency/conflict within the family can be quite high. The gender nonconforming child’s needs understandably take center stage. Sometimes, however, this state of crisis continues for a prolonged period of time. A sibling can recognize the challenges experienced by the transgender child and subsequent higher demand on family resources and, at first, adapt to the decreased attention. They may make an effort not to bring any “extra” challenges into the family and, initially, deemphasize or minimize their own needs. This is neither ideal nor sustainable. Overwhelmed parents can inadvertently sideline a sibling’s needs or experiences.
By the time a family has weathered much of the early gender-related crises or transition hurdles, they may realize that a sibling is suffering. Siblings of gender nonconforming children often experience greater teasing. Parents may see a decline in school performance, acting out, depression, or anxiety. What may be harder to notice is when a sibling overcompensates by being overly helpful or accommodating.
Sometimes a sibling will inadvertently disclose a child’s gender status without realizing the potential repercussions. A sibling may also deliberately disclose in an effort to be a part of, or gain some ownership over, an issue that has taken center stage for the family. While this is a normal response, the repercussions can be life altering for the gender nonconforming child and the family as a whole. Siblings should be made aware of why privacy is important.
Parents should find dedicated time for each child regardless of the increased sense of urgency related to the gender nonconforming child. Create one-on-one opportunities where the focus is solely on the sibling. An ounce of prevention is far better than having two (or more) children in distress. If at all possible, it can be advantageous to find a therapist or group for the sibling. It is not always necessary to find supports that are well versed in transgender issues and can be more important to identify a therapist who has experience working with siblings of children with any kind of special need.
There are many things we can do at home to assist children in developing good mental health. Often, for gender nonconforming children, it is also helpful to bring in an experienced therapist.
One of the greatest gifts we can give a child is to help them build their emotional resiliency. The world can be a tough place for a gender nonconforming child, even those children whose families are fully on board. It is critical to build healthy coping skills. It can mean the difference between a child who knows how to empower themselves and a child with poor self-esteem and greater likelihood of victimization. It is common for gender nonconforming children to experience varying degrees of anxiety and/or depression despite having identity-affirming support. Having an atypical gender in a narrowly gendered world can be a hefty burden. Studies have shown that the development of a strong emotional resilience can result in greater success in school, stronger friendships, and being less likely to experience depression. If a child is aware of how they feel and has tools to move through their intense emotions, they will have acquired a skill that will last a lifetime. In order to help children recognize their emotions, we, as adults, need to spend time thinking about the underlying causes for a child’s emotions and talking to them about how to identify their feelings. Many times, an angry outburst actually comes from a place of fear or shame.
In addition to teaching children about their own emotions, we have to teach them about the emotions of others. Children who are taught that insensitive comments often result from ignorance can be sad and disappointed but also compassionate. As adults, we can model this kind of resiliency when dealing with comments from other adults in front of children. We should be ready to address or deflect comments in ways that show confidence and support for a child. If we are having difficulty doing this, it can be important for us to spend time talking with family members, friends, or our own mental health providers about the feelings we are having, while continuing to model appropriate responses for the child.
Many, but not all, transgender or gender nonconforming children have negative relationships with their bodies, or specific parts of their bodies, feeling a sense of betrayal that their bodies are not in alignment with how they feel. These children may have an extremely difficult time developing an attuned body awareness. Efforts should be made from an early age to encourage gender nonconforming children to participate in dance and sports, activities that can put them in touch with their bodies and give them pride in their bodies’ accomplishments.
Johnny Science in a King Arthur costume from Christmas morning in 1959. Johnny transitioned in the mid-1980s and died in 2007. He was an artist and musician and organizer of the trans community in New York City in the 1980s and 1990s. He hand-colored this childhood photo of himself (courtesy of Kit Rachlin).
Mental health providers such as psychologists, psychiatrists, and social workers can be wonderful allies to gender nonconforming children and their families. Some of these providers have chosen to specialize in working with transgender children and can also be great resources to connect families with support groups and other services. They often work in conjunction with physicians, who manage children’s general physical health as well as assist families with decisions about important gender-related medical care.
When selecting a mental health provider, look for one that is knowledgeable regarding gender nonconformity and transgender issues. This provider should be one who can distinguish between a child’s gender expression (interests, clothing choices, etc.) and their gender identity. An optimal provider will be one who starts with a holistic assessment of the child and their family to ascertain all variables that impact that child’s life. To adequately assess a child’s gender identity and state of exploration may require several sessions and include discussions with the child, parents, and sometimes siblings. The ideal provider will simultaneously be paying attention to the child’s gender concerns, determining familial comfort or distress, assessing supportive networks for all family members, and addressing issues of possible anxiety, depression, behavior, and any other concern regarding the child’s health and well-being.
It can be extremely valuable to establish a relationship with a mental health provider early in a gender nonconforming child’s life. Not only can providers be important resources and supports for both the child and their family, but they can also be strong advocates for the child’s needs when the child approaches a time that the family is considering puberty blockers or other medical interventions. Most medical providers require a child to have a relationship with a mental health provider in order to start puberty-blocking medications, and families have found themselves rushing to establish relationships when puberty is starting.
Not all mental health providers are the same. Gender nonconformity is not a required part of most mental health curricula for those in training to work with children. Some providers believe that gender nonconforming behaviors should be suppressed or discouraged. Proximity to larger cities can make it easier to connect with knowledgeable providers; in more rural areas this can sometimes be extremely difficult. Some families have found that they do not mind educating their child’s mental health provider about these issues as long as the provider is open and affirming. Others prefer to travel longer distances to see someone who is more extensively trained around gender nonconformity. We should always look for the best fit for our families, even if it takes seeing a few different providers for evaluations in order to find the person with whom we will work best.
It is not uncommon for gender nonconforming children to be diagnosed with one or more behavioral conditions as a child’s family seeks the source of their child’s unhappiness. Considering the direct inquisitiveness or teasing of other children, the subtle or direct disapproval from some adults, and the rigid gender stereotypes presented by society, it is no wonder a gender nonconforming child may have behavioral challenges, including outbursts of anger, times of being withdrawn, feelings of anxiousness, sadness, despair, and depression. If children feel boxed in or trapped, their innate selves rendered invisible, it is quite likely that behavioral issues may manifest. Children may also feel they are under considerable pressure from family and peers—even society as a whole—to conform to rigid gender expectations.
It is important to recognize the possibility that a child’s frustration, anger, or despair may originate with the fact that they are not being recognized or acknowledged for who they are. Many families have found that when they finally acknowledge and support their child’s gender identity, other behavioral issues decrease or simply fade away. In some cases, there are other underlying issues such as depression or attention-deficit/hyperactivity disorder (ADHD) that could be contributing to a child’s behavior. Thus, it is important to involve a knowledgeable, caring mental health provider to help sort this out.
Occasionally, even if gender is acknowledged as a factor in need of being addressed, it can be assigned a secondary “ranking” by a less knowledgeable provider, which can indefinitely postpone treatment or support for a gender nonconforming child. A therapist might suggest addressing gender issues once anger, anxiety, depression, or behavioral outbursts are under control. These issues should be considered alongside gender identity, but they are not more important.
Among transgender adults there is considerable debate over the categorization of transgender identity as a mental disorder. The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) renames gender identity disorder as gender dysphoria. Families who are raising a transgender child often grapple with the ramifications of a child being diagnosed with gender dysphoria.
Gender dysphoria in childhood is defined as a period of at least six months of a child experiencing a difference between their expressed and assigned gender, and which causes significant distress or impairment. While many parents recognize that there is nothing “wrong” with their child’s mental health—only ignorance and bias in our society—the advice from medical, mental health, and legal professionals may be to obtain a gender-related mental health diagnosis. There are various reasons for doing so, which may include insurance coverage, access to hormone blockers, and even divorce or child custody issues. Arriving at a definitive diagnosis can also be comforting for many parents as it is concrete and paves the way for specific action such as ID and school records changes.
It is important to recognize that there are pros and cons to a child receiving a diagnosis of gender dysphoria. Diagnoses remain permanently in medical records. There are a number of opportunities, services, and situations where a mental disorder diagnosis could potentially prevent or greatly hinder someone’s access—either now or later in life. Insisting on a label could potentially serve to silence a child and squelch any further attempts to find their authentic self, which may or may not be as a transgender adult. In an effort to decrease the discomfort of their parents and others, a child may make choices that are not aligned with how they actually feel. A diagnosis can also lead to a later situation where a child “changes their mind” or says they have “made a mistake” simply because they felt pressured to make a decision before they were ready. Each family should educate themselves as to the potential benefits and repercussions of obtaining a gender dysphoria diagnosis.
Steven, 10 years old.
Many families come to a point where they feel that the best thing for a gender nonconforming child will be to support the child in expressing their gender identity publicly. Parents may have already spent considerable time allowing the child to try out different clothes, names, or pronouns at home, or with select groups of peers and other parents. For parents considering social transition for their children, there are a few concrete steps to affirm a young child’s gender. These can include all or some of the following:
• Changes in hairstyle, clothing, preferred toys, or accessories
• Name change
• Pronoun change
• Identity document changes
• A reversible, medical delay of puberty
For some parents, these tasks seem quite daunting. For others, especially those parents who tend to cope by finding solutions and implementing them as quickly as possible, having tangible, concrete actions to focus on can provide a sense of relief. While these tasks often do need completing, some may not. Some may be premature or simply not applicable to every child.
It is easy to focus on this “checklist” of transition-related tasks. It can provide a parent with what feels like a step-by-step through unfamiliar territory. Moving quickly through these tasks may provide some comfort, or a sense of purpose, but it can also result in a bit of tunnel vision that can hamper a parent’s ability to see other more immediate issues. It can also send a message that a child “needs” to transition fully when their gender identity is of a more fluid state and transition is premature or not necessary.
Even if all these tasks are necessary, it does not mean they are easy to accomplish. It is quite common to encounter barriers within systems (e.g., the rules dictating ID document changes can vary state by state). These barriers are often not insurmountable but can take an incredible amount of time and require legal assistance. It is important to pace ourselves in order to avoid burnout, financial hardship, or an overall drain on our day-to-day life experience.
For parents, teachers, and therapists ready to help children with social transitions, one of the biggest fears expressed is that we are moving too fast, and that the child may “change their mind.” A decision to transition a child’s gender can feel like an irreversible course of action. When a trans adult transitions, some steps, like hormones and surgeries, do change the body in permanent ways. This is not true for a child pursuing a transition. A child’s transition primarily consists of a “social transition” where no permanent physical changes are made.
Many times, fears are larger than reality. It can be helpful to actually “play out” a scenario in which the child does change their mind. Say that a family supports their child in a social transition. The child takes on a different name, perhaps changes their hairstyle, is supported in their clothing preferences, uses the bathroom that aligns with their gender identity, and everyone works very hard to get the new pronoun to easily roll off their tongue. Then the child comes home one day and says, “I want to go back!”
If a child states that they made a mistake or that they want to go back to the gender they were before, simply work the aforementioned steps backwards. These steps are all reversible and it surely will not be as hard as it was the first time. This is not to say that it will be easy. A parent will still be placed in the position of explaining to others why “supporting” their child includes a gender transition and, if need be, a change “back.” As those caring for gender nonconforming children, our fears about a child “changing back” may be more about our own shame at having been “wrong” than about concerns for the child’s safety or well-being.
Gender Odyssey Family Conference, the Gender Spectrum Conference, the Gender Infinity Conference, and Philly Trans Health Conference all offer programming for gender nonconforming children and their families.
The first step for many families in social transition is to inform extended family members, parents of a child’s friends, and school officials that the child is going to be transitioning gender. When disclosing a child’s gender experience, keep in mind that it is impossible to accurately predict a person’s reaction. Those who we think will be supportive right away may not be, and those who we fear telling the most can sometimes be surprisingly supportive. It is best to proceed cautiously with each person. Positive outcomes are significantly higher when parents exhibit their own confidence, without hesitancy or shame.
There is no doubt that creating a network of support involves a fair amount of work. Most people, unless their lives have been touched by a transgender person, have had no opportunity to learn anything about this issue at all. Finding support from your extended family and your neighborhood may take time and patience, but expanding your network of support will provide a very worthwhile payoff. Families that take the time to sit and discuss this issue with others find that, while some people are unreceptive, many more are supportive. Do not spend a lot of time trying to reach people who are displaying a high degree of resistance. It can deplete your energy and sometimes serves to increase the resistance. Some may never come around. Some people may simply need some space and time to navigate their feelings before they are able to find some level of understanding.
“My sister was really angry when we discussed with her what was happening with our transgender son. She had strong opinions and was not willing to listen to me or read anything that I suggested. We mostly stopped seeing her for a while, which was really hard, especially on our son, as her children—his cousins—were really close. But, we kept going to family functions and everyone else came around, especially when they saw how happy he was. My sister’s children started to push back and asked more questions about why we all weren’t spending time together. They wanted to know what the ‘big deal’ was. After a little while, she just seemed to let go of all her resistance. Things are back to normal now—even better really—and I am so glad I didn’t pressure her. She seemed to need the space.”
Statements that can be made to connect with people who are having trouble understanding your family’s decision to support a gender nonconforming child:
• At first, we too were really confused by this issue with our child. This response can serve to validate someone’s confusion. They may be too embarrassed to admit they know nothing about transgender issues.
• I was angry at first, too. It seems so unfair—I didn’t ask for this! A response like this can work to validate and diffuse the unexplained anger or rage a person may be feeling.
• I was scared for my child’s safety and what this issue might mean for our family. Expressing fears can validate the fears of another. Some people wonder whether their own children will be safe when around a trans child. While this is quite offensive to hear, it is the reality of what some people think.
• We were unsure whether we were doing the right thing at first. There is so little information out there. But then our doctor gave us some good advice and resources. This can help dispel the notion of overly lenient parenting while at the same time communicate that you have received professional guidance.
There can be situations when these steps do not work and things become quite volatile. These are dangerous. If you perceive a sudden or extreme negative response in another person, do whatever you can to remove yourself from the situation calmly and quickly.
Dear Family,
We have some big news to share, so we thought it best to write you personally. Our child, who you know as Lacey, has shared since she was two or three years old that she feels she is a boy. Not that she wants to act like a boy or play boy games, but she feels like she was born a boy. We have, in fact, learned we are not the parents of a little girl, but the parents of a little boy. Through long and careful exploration, discussion, prayer, therapy, family talks, and careful self-reflection, we have come to understand this new truth. We are proud and excited to introduce a new but old member of our family, Justin!
Justin, as he is now known by everyone in our neighborhood and school, is living full time as a boy. He is unbelievably happy and comfortable about this big change and so are we. As you are a very important part of our lives, we decided to also share this truth with you. We understand this may be confusing. In the beginning, we too felt confused. For years now Justin has told us how he feels inside with the words he knew.
There is plenty of information available about transgender children—we invite you to explore this information as we have. There is quite a bit of information on the Internet. There are also several good books on the subject. We recommend The Transgender Child and Gender Born, Gender Made.
We request you welcome Justin fully as part of our family. Please refer to Justin only with male pronouns (he, him) and by his name, Justin. Despite any personal reservations you may have, we expect and hope you will be fully welcoming, respectful, and kind to Justin. All the experts we have consulted on this subject agree this is the right approach for maintaining Justin’s mental health and happiness long term. Transgender kids are much more prone to suicide, depression, and self-harm when they don’t have the support and love of their family.
If you are no longer able to treat our child with complete respect, we will decline further contact until that changes. Regardless of religious belief, all of us as parents want our children happy and safe. Our friends, community, and Justin’s school have been extremely helpful and supportive. Our love and support for Justin is complete. We hope yours will be also. We love you all so much and miss you.
The Johnsons
It is critical to prepare gender nonconforming children for questions, whether they come from an inquisitive child or an insensitive or unthinking adult. Some people will let their curiosity override their sense of what is appropriate to ask of a child. If you do not think an adult would ever ask a child if they are going to have a sex change operation, think again!
Children ask questions that are simple and address immediate curiosities. Simple answers are highly effective. Adults may have a different agenda. They are more likely to couch their questions in politeness and express their discomfort or disapproval in more subtle ways. A young child may sense an adult’s inappropriate agenda but not be able to articulate what they perceive to others, including a parent or a therapist. This is where the attentiveness of the supportive adults in a child’s life is critical. One option is to tell your child that they do not have to answer any gender-related questions from adults. Equipping a child with a response like “My mom says you shouldn’t ask me questions but should come talk to her” can immediately relieve a child’s pressure to respond. If the adult persists, tell the child to find their parent immediately.
It is ideal to talk with children about how to address questions from different types of people. Is the person a friend at school? A favorite cousin? How should the answer be different if the person is a stranger? Remember that siblings of transgender and gender nonconforming children have to navigate these waters as well. Discuss scenarios and questions that they may have already encountered. Some children have “outed” their trans siblings and need their own guidance and attention to negotiate whatever situations arise. Young children may not yet understand why respecting someone’s privacy is so important. The desire to tell a “secret” can be high, so it is important to discuss with children the importance of privacy in anyone’s life. Additionally, children should know that there are safety issues at hand.
One activity shown to be highly effective in building resiliency in children is role playing. This involves the creation of any number of potential situations where a child might need to think on their feet. The parent or other support person plays the role of one person and the child practices potential responses. This can be helpful in any number of situations.
A whole family can engage in role-playing exercises and the whole family can benefit. To start, brainstorm potential situations and list them on paper. These can include school scenarios and even be narrowed down to specific students who may be benignly persistent in their questions or others who are aggressively teasing and bullying. It might include an upcoming family reunion and seeing relatives for the first time since affirming a child’s gender.
“My son who had socially transitioned at a young age was having a conversation recently with a friend who’d known him for a long time. His friend said, ‘Hey, didn’t you used to have a girl’s name?’ My child just shrugged, rolled his eyes, and said, ‘Yeah, can you believe my parents named me that!’ Both kids laughed at how silly adults can be and went on to something else. We’ve done a lot of role playing and it paid off. He really thought on his feet.”
Role playing should not be limited solely to the gender nonconforming child. Parents need to be prepared to address the gender question at any time and with any person. That is not to say that an in-depth explanation—or any explanation for that matter—is necessary. However, parents need to envision a number of scenarios and determine what, if any, explanation is needed depending on who the person is, what degree of relevance they have in the family’s life, how much time they have at that moment, and their assessment of that person’s receptivity.
Scenario: You are in a grocery store with your eight-year-old trans daughter and you see someone you know from your neighborhood. They say hello, seem confused when you mention your daughter, and then inquire about your son. You are a little caught off guard and do not quite know how much to say, but end up providing an explanation about how your daughter used to be your son, that you became aware that he was transgender, and that now you support her in her true gender identity as a girl. Your neighbor has an uncomfortable smile on their face, comments on your bravery as a parent, says they wouldn’t know what to do if they had a child like “that,” and then moves on down the aisle. Your child seems to have been thoughtfully contemplating the cereal boxes the whole time and because your child says nothing, you say nothing.
Inherently, this response to an unexpected situation was handled pretty well. A brief educational response may be just the thing for an unexpected supermarket interaction. But there is a really good chance that your child was listening to all that was said. She could have easily stolen a glance or two at both you and the neighbor as the conversation progressed, felt the discomfort of both adults, and registered how quickly the neighbor moved away. The child can internalize this discomfort and develop a sense of shame about themselves. Because this was not addressed by the parent afterward, it could cause a child to conclude that their parent’s own discomfort comes from a sense of shame they have about her. This unintended consequence, instilling shame and silence, can be long lasting.
Here are two examples of responses to the above scenario that elevate family support and trust as the number-one priority.
Example Response 1: You are in a grocery store with your eight-year-old trans daughter and you see someone you know from your neighborhood. They say hello, seem confused when you mention your daughter, and then inquire about your son. Because you have done your own preparation, you are not caught off guard. You say, “No, I only have a daughter” and that’s it. You allow them their confusion as you excuse yourself and say, “Sorry I have to run. It was nice seeing you,” leaving them with a quizzical look on their face and a very relieved child.
Example Response 2: Perhaps this is a family with whom you would like to discuss your family’s journey but you recognize that the grocery store is not an ideal place. You take the lead in the conversation and say how nice it was to run into them. Then you mention that you have been meaning to stop by and visit them and ask whether they are going to be around tomorrow morning. If they ask a question about your child, you gracefully state that you would love to catch up with them soon and if tomorrow does not work, you will call them to find another time.
Have fun with role playing. Try out silly responses along with your serious ones; shout out some one-liners, or speak them using your favorite accent. If a child is relaxed and having fun during the role playing, chances are they will be able to bring some of those feelings into real-life situations.
Many gender-diverse children are eager to shed their gendered names assigned at birth. This can be a difficult task for a parent who may have put careful consideration into selecting their child’s name. It is normal to feel attachment to a child’s name and grief at the thought of it changing. Many parents also worry that giving a child too much leeway in choosing their own name could result in a choice that the child is upset about later in life. Young children often choose silly names, such as those of Disney characters or other toys. The amount of influence the child has in decisions related to name changes depends greatly on the age and developmental level of the child.
Some parents feel it is important for their child to have a family name, or one that fits well within their culture. Many families have trial periods, where the child’s new name is used at home or among family members to be sure it is a good fit. Some children may try multiple names before settling on one. Gender-neutral names can sometimes be good choices because they allow for children to explore their gender identity without making any big decisions.
Legal name changes take time and money. Taking legal steps can be very important in many cases in order to affirm a child’s identity. However, holding off on a legal name change does not mean that a child needs to be addressed by their birth name at school or in a health provider’s office, as these entities often have options for the use of a child’s nickname or preferred name. Changing a child’s legal name generally follows the same process as that for adults, but it requires the approval of a parent or guardian. See Chapter 10 for more information about how to make a legal name change.
While pronouns are among the smallest words in the English language, they are a highly structured part of our speech. Within a moment of meeting someone for the first time, we assess that person’s gender and begin to use male or female pronouns to refer to them. In rare circumstances where we misgender someone, we often feel mortified—for them and for ourselves. We may stumble over our words and quickly apologize.
Taking a Gender Vacation
While not an option readily available to all, there are some families who will opt for a trial “gender vacation.” If your family has a trip out of town or to someplace where you are not likely to run into people you know, consider testing the waters by giving your child an opportunity to adopt their preferred gender clothing choices, pronoun, or even a different name while away from home. Many parents have been quite surprised at how happy and at ease their child is as well as how uneventful the temporary “social transition” is as they see how society readily receives their “new” daughter or son.
It is no wonder that there is so much resistance to considering a pronoun change for a child. Allowing a child to switch pronouns can, for many adults, feel as if they are, at best, aiding a child in an imaginary unreality or, at worst, assisting in an act of deception.
For adult trans people, changing a pronoun can feel like a monumental step. For a child, however, it can be a simple and straightforward validation of who they feel themselves to be. For children who strongly cross-identify as either male or female, the pronoun that aligns with their gender identity is the obvious choice. That being said, not many adults are adept at switching pronouns quickly. It takes practice, as well as acceptance of a child’s innate gender identity, to make a new pronoun flow off the tongue with ease.
When a child’s gender identity is less definitive, it can be harder to know which pronoun to use. The best place to start is to simply ask the child whether they want to be called he or she. The answer you get might be “neither,” “both,” I don’t care,” or even “I’m just me!” Older youth and adults are creating alternative pronouns like zie, hir, or even the plural they. These are options for children. Using no pronouns at all is also an option.
It is a little awkward at first, but most people can readily adjust to addressing a child without using pronouns (sometimes simply substituting their first name) or using pronouns interchangeably. Be assured, this act in and of itself will not change a child’s gender—it is simply being respectful of what that child tells you. Additionally, it creates a little more breathing room for a child to explore gender in a less restrictive way.
Outside of home, most children spend the majority of their time at school. Unfortunately, gender conforming expectations exist at most schools and at every age level. Pressure to conform can come from peers and teachers alike and in varying degrees. These expectations are present in school traditions and policy. Even the most progressive schools can have practices or policies that unintentionally marginalize or silence a transgender student.
For many teachers and administrators, the desire to be inclusive within the school community is strong, but the knowledge of how to do this is limited. Many schools and districts are willing to help but need a road map for creating a gender-inclusive environment. A school pursuing a healthy, inclusive, and safe community is well poised to incorporate the concept of gender diversity into its existing framework.
Many schools have the capacity to create an inclusive environment for trans students without any major overhaul. Administrators, teachers, and other staff can prepare to care for the needs of gender nonconforming children in a number of ways. Here are a few:
1. Gain familiarity with specific questions that may arise from students or parents and become confident in providing knowledgeable answers
2. Address classroom situations/questions in a manner consistent with other areas of diversity
3. Create and/or implement school policies that specifically name gender identity and gender expression
Some schools are excited to be on the cutting edge of trans student rights, but many are not, at least not at first. Many, however, are happy to ride on the coattails of schools that have successfully implemented trans-inclusive practices. Knowing that other schools have broken this ground with little controversy and to the benefit of all students can mean all the difference in the world. Fortunately, a number of schools have done this work and can provide other schools and districts with successful experiences and model policies.
Lisa Love, MEd, works in Seattle schools overseeing LGBTQ programs, health education, and prevention efforts.
The Seattle Public Schools’ Health Education Office has worked with students, staff, and families to address issues regarding sexual orientation and gender identity since roughly 1987. We already had inclusive policy language, which specifically identified gender identity and expression within its protected classes. What we did not have was a procedural guide for school administrators. Using our Washington State Healthy Youth data and our Youth Risk Behavior Survey data, as well as our estimates of numbers of students needing support in our schools, we made a strong case to district administrators and the legal office in support of needing a Superintendent Procedure. We convened a group of parents, community members, and staff to gather content input, and we also collected sample language from other states and school districts.
We reviewed language from a few other existing district policies and some national model policies. After much tweaking, wordsmithing, committee reviews, and meetings with students and families, we finally had a draft Superintendent Procedure for addressing the most common questions asked by school administrators and families. Our draft, Superintendent Procedure 3210SP.C, was in an almost-final version and slowly made its way through the vetting process within our school district. While Seattle is a progressive city, it was not always easy to move things forward. Many questions and concerns were raised by everyone from principals, to people in the enrollment office, to PE teachers, to folks who address the district technology systems. When we had nearly half of our approval signatures, the process was halted to gain even more input. Administrators expressed concern that we did not have enough buy-in from those in Operations. Another committee was convened. In the end, everyone was on board with moving forward and the document was signed by the Superintendent. Some of the key policies in the document include the following:
• Names/Pronouns: Students shall have the right to be addressed by a name and pronoun that correspond to their consistently asserted gender identity.
• Official Records: The District shall change a student’s official records to reflect a change in legal name or gender upon receipt of documentation that such legal name and/or gender have been changed pursuant to Washington State Law.
• Restroom Accessibility: A student should be provided access to a restroom facility that corresponds to the gender identity the student consistently asserts at school.
• Locker Rooms: Schools may provide a student access to a locker room facility that corresponds to the gender identity the student consistently asserts at school.
• Sports/Physical Education (PE) Classes: Transgender and gender nonconforming students shall not be denied the opportunity to participate in PE or extracurricular activities.
• Dress Codes: Students shall have the right to dress in accordance with the gender identity they consistently assert at school, within the constraints of the dress codes adopted at their school site.
• Gender Segregation in Other Areas: As a general rule, in any other circumstances where students are separated by gender in school activities, students shall be permitted to participate in accordance with the gender identity they consistently assert at school.
Each state has a governing body that oversees education at a state level, with a set of guidelines governing discrimination against students. Contacting these officials or obtaining a copy of the guidelines can be good first steps for approaching a school district about the needs of a gender nonconforming child. Local school districts may also have their own policies. As recipients of federal financial assistance, school districts are obligated to follow federal civil rights laws and regulations, including Title IX of the Education Amendments of 1972, which prohibits discrimination in education on the basis of sex. A number of precedent-setting cases are making evident that discrimination based on a person’s gender identity or transgender status does indeed constitute sex discrimination and falls under federal protections. Learning all you can about any existing policies and guidelines relevant to your school, municipality, and state will better equip you to advocate for your child within the legal expectations rather than being perceived to be requesting special considerations.
Discussing gender inclusivity with a person in a position to effect change on a school-wide basis is important. Think about who would be the strongest ally within your local school system and reach out to that person. It may be the principal, vice principal, a teacher, or school counselor. Tell them that you would like to hear about what practices they already have in place and how you can help them to create a safe, healthy learning environment for all children. Ask them whether they have had transgender students in the past. If so, was the student private about their gender history or was there open knowledge of the student’s status? How did the school protect the student’s privacy and protect the student from teasing or marginalization? What are the existing policies in relation to bathrooms, locker rooms, and other gender-separated spaces?
The head of the school is responsible for enforcing the legal requirements for both preventing discrimination and maintaining an optimal learning environment for all students. Administrators are often unaware of how to create this optimal environment and minimize/eliminate instances of teasing or bullying in relation to gender identity and expression. Many are appreciative when provided with educational or training resources. Sometimes an administrator is resistant or hesitant to learn from parents themselves. Training organizations or gender advocates can be very helpful in situations like this.
A great starting place for any school is to examine the school’s inclusion policy. It is important to update existing antidiscrimination language and any other guidelines. This serves to set the tone for the entire school community. Review the school’s mission statement or school handbook. An ideal mission statement will include language that takes a stand against discrimination based on gender identity and gender expression. If this terminology already exists, it is likely that the school has already encountered gender-diverse students. It may not mean that the school has everything figured out with respect to the unique day-to-day situations related to gender nonconforming students, but it at least provides a place from which to launch your work. It is important to note that a broadly worded antidiscrimination policy is not enough. The most successful outcomes for gender nonconforming children and the entire school community come when gender identity and gender expression are clearly stated.
Once school administrators are ready to increase their knowledge and understanding, it is ideal for the full staff, parents, and students to receive training. While individual teachers who have direct, daily contact with a trans or gender nonconforming student are often ready and willing to address gender inclusivity within the classroom setting, it is extremely beneficial to have both the support of the administration and the participation of the whole school community. Other students, their parents, and teachers often have questions or concerns, especially at first, regarding the presence of a transgender student at a school. There are organizations, such as Gender Spectrum, Gender Diversity, and the Gay, Lesbian, and Straight Education Network (GLSEN), that offer specialized training in this area. While it involves the investment of time to educate the students, teachers, and support staff at the outset, the end result will benefit any existing students as well as the future trans and gender nonconforming students that will come.
It is important that all staff receive education on gender nonconformity and trans identity. Teasing and bullying can occur on the bus to school, in the classroom, in the lunchroom, in the gym, or during after-school programs. Every adult needs to have familiarity with issues that come up for trans and gender nonconforming children.
When seeking a qualified trainer, look for someone who can offer the following:
• An explanation of gender variance and the ways it is expressed in children of all ages
• Definitions and in-depth explanations of gender-related terminology
• An overview of current research regarding gender variance and children
• Information on legal issues, obligations, and best practices for schools in relation to trans students
• Basic strategies that allow all students to safely navigate classrooms, play areas, lunchrooms, bathrooms, and school trips
• Direct antibullying and harassment methods related to issues of gender diversity
• A safe environment for teachers to learn more about trans students and issues
Schools that have undertaken trainings have been delighted at the positive outcomes. Principles and concepts learned in a training can later be built into academic lesson plans, classroom conversations, and will also serve the purpose of enhancing the overall culture of acceptance at the school. Teachers and administrators alike who, at the outset, were cautiously optimistic, express great excitement and satisfaction when witnessing the ways young students engage in conversations about gender.
One first-grade teacher had this to say:
“Despite my increased understanding of gender [from the training], I was still nervous about how the kiddos might react. Would they accept that Sara was now JJ and that ‘she’ was now ‘he?’ And I was still really worried that the conversation about gender differences was too mature for them. Wow, when I saw the encouragement and support sent JJ’s way, I was so moved. Then I heard how excited the kids were to talk about their own gender and how much they all felt the gender ‘squeeze’ restricting what they could do, and wear, and enjoy! I felt like I was a kid again and was reminded of the simplicity of gender at that age. Amazing!”—Teacher reporting on a classroom training led by Aidan Key
Parent education opportunities allow parents to gain an informed understanding of the training the school is undertaking as well as the education the students are receiving. Offering education for parents creates a way to increase parental awareness of this topic and answer any questions they might have. It can help to relieve parental concerns as to whether this topic is age appropriate for their children and culturally relevant. In trainings, parents are informed of the school’s legal obligations with respect to local, state, and federal antidiscrimination policies as well as the school’s own policies and approaches.
A qualified presenter can structure an evening of parent education as a stand-alone presentation or a facilitated presentation that includes a panel discussion. Panel members may include a gender identity therapist, teachers, parents of trans children, and trans teens and adults. One of the most valuable ways to shift those who may be fearful or resistant to discussions of gender diversity is for them to hear real-life stories of those who are walking this path.
Parents of other children often have lots of questions and feelings about gender-related discussions in school. These may include the following:
• Won’t this confuse my child?
• This does not align with my faith.
• What will you say to the children in the classroom?
• Which child at the school is transgender? Don’t we have the right to know?
These are questions worthy of response. Offering parents a chance to ask questions will greatly relieve their concerns and better equip them to continue the conversation with their own child in a more informed way.
Many parents express great delight when they hear how their own children respond to discussions of gender. One parent, who came to a parent education night, had this to say:
“I pick up my third-grade daughter from school every day and I always ask how her day went. She always gives me a flat, ‘Okay.’ Today, I picked her up as usual, but this time she wouldn’t stop talking! She said people came to her class today to talk about ‘being different, ’ and that she got to share how she was different! I’ve never seen her so excited. She had no problem understanding how a person might feel like they were a different gender, even though she doesn’t feel that way herself. But, she says, ‘I know how it feels to be different and I get teased for that.’ When class was over, she said all the other kids made an agreement to no longer tease or be mean to each other. Whatever you talked to those kids about today in class, I’d really encourage you to keep doing it!”
Children have different ways of understanding gender at different developmental stages. It is important to frame concepts in ways that children can understand at each of these stages. Parents and teachers can have age-appropriate conversations with children starting from very young ages about gender identity, gender roles, and the social expectations we have about people based on their gender assigned at birth.
A discussion about gender variance is a simple conversation and one that is quite exciting for most kids. Young children are eager to talk about gender and how it relates to the clothes they wear, the games they play, and how other children treat them. Children are able to easily challenge society’s gendered expectations about the things we wear, the things we like, the things we want to do, and how these expectations are unfair and restricting. Children can readily articulate the inequities they experience as a result of their gender.
“It’s not fair! Girls get to wear dresses, skirts, pants, and shorts—we just get pants and shorts. Girls get to wear any color they want! We get brown, blue, and black.” —seven-year-old boy at a Gender Diversity classroom presentation
Children are also quite capable of understanding the parallels between diversity in gender and other aspects of a person’s identity. When asked about the reasons for which any of them had ever been teased, second graders in a classroom presentation provided these kinds of answers:
• Kids tease me because my family moved from Korea last year and I didn’t know any English.
• People tease me because I’m adopted.
• I get teased because my skin is darker.
• I’m the tallest kid in the class and a girl. I get teased for that.
• I get teased because I have two dads.
• Kids tease me because I have a little skin tag by my ear.
Children are naturally curious about new things and, of course, have questions. What is important to remember is to provide a direct answer to a direct question at the level the child can understand. When talking to children about gender nonconformity, we often worry that we are going to confuse them. There is no need to delve into mature or complex explanations beyond their developmental capacity. For example, a six-year-old child might make this comment about her friend: “Jason looks like a boy but says he’s a girl!” A direct way to respond would be to say, “Yes, it may seem confusing at first but what Jason is saying is that, while he may have the body of a boy, he has the heart and mind of a girl. Some kids feel that way and perhaps you didn’t know that.”
Parents, as well as teachers and other providers, can use opportunities like these to talk with children about gender. Bringing these conversations directly to children of all ages can serve to dramatically lessen bullying between children. It provides children the opportunity to practice inclusion, respect, and compassion.
Bathroom transitions can be a source of intense debate among parents and school officials. There are a number of issues that emerge when families and schools begin talking about which bathroom a trans or gender nonconforming student will use.
The first step in deciding on the correct bathroom for a trans or gender nonconforming child is to spend time talking with the child about where they feel they belong. All children should use the restroom that best aligns with their gender identity. For trans boys, this is likely to be the boys’ restroom and for trans girls, the girls’ restroom. Children who have a more gender-fluid identity should use the restroom that provides them the greatest degree of comfort and safety.
Parents of gender nonconforming children often indicate that their main concern about which bathroom their child uses at school is where they are going to be the most safe. Parents may worry that their child will be teased or physically assaulted. Often the greatest fear is expressed by parents of trans boys who assume that the likelihood of violence is greater in the boys’ bathroom. Parents of trans girls also express concern, not so much for physical assault in the bathroom, although that can occur, but for verbal harassment and ostracism.
Many adults are concerned with how children will react when a trans student changes bathrooms. The best way to predict how children will respond is to take a look at how the adults in the children’s environment are responding. If the school leadership approaches the “bathroom question” with a matter-of-fact, respectful approach, this provides an excellent example for the children to emulate. Sometimes children are ready for a change even before adults come on board.
Occasionally there are students who are truly uncomfortable when sharing a bathroom with another student who is transgender. Or perhaps a trans or gender nonconforming student is not comfortable using either the boys’ or the girls’ bathroom. This can happen for a variety of reasons and may or may not be temporary. School districts are adopting policies to meet the needs of any student experiencing discomfort by offering the use of an alternative restroom such as the staff or nurse’s bathroom. The important distinction to recognize is that this option is not being forced on the trans student and it is one available to any student desiring the need for increased privacy.
Many parents are unaware of what can occur when their child does not have a safe and accessible bathroom. Some gender nonconforming children avoid using the bathroom at all at school. Many parents are shocked to discover this and may only become aware of it when their child develops a urinary tract infection, kidney infection, or suffers from dehydration. Trans children will sometimes avoid drinking any fluids during the day to minimize the need to urinate. If a child is not provided with the appropriate restroom, they may simply make a choice to “hold it.”
Some schools have felt like an acceptable “middle ground” means providing the youth with an alternative bathroom such as one in the nurse’s office or in the teachers’ lounge. This can work in some temporary situations, but a child may even avoid this option if it draws unwanted attention to them, so it is important to find out from the child if they feel comfortable using the new bathroom they have been assigned rather than assuming they will use it if they need to.
When a school begins to talk about a student transitioning bathrooms, parents of other children may have strong reactions. They may express concern that their children will not be safe when a transgender child is in the bathroom. This feeling is not exclusive to other parents and may even be felt by principals, teachers, or support staff. They may vocalize their fear or concern and yet be unable to articulate exactly why they are afraid. These vaguely defined concerns directly tie into our cultural fears and misperceptions of who trans people are—at least who we have been led to believe they are—and that includes imposters, sexual deviants, or people who are mentally ill. Many adults subconsciously project these misperceptions onto even very young children.
In a Gender Diversity training session, one elementary teacher expressed her concern for the safety of other girls in the restroom if a trans girl were to begin using the bathroom. When asked to expand on her concern, the teacher said she was fearful that the other students would somehow see the trans girl’s penis. When the leader inquired as to how she thought that might happen, she said, “Well, you know, girls might look over the walls of the stall.” The leader suggested that the trans girl in the stall would feel more frightened by this behavior than the other girls. The teacher nodded her head in agreement, as if by speaking her fears aloud, it was made evident which student would be traumatized by this scenario. She learned that this was not a gender issue; rather, this was an issue of bad behavior. Any student looking over the stall wall at another was violating the other child’s privacy and deserving of some form of intervention or discipline. All in the room agreed.
Use of public restrooms in places like airports, malls, restaurants, and other highly trafficked areas are often concerning for parents of children who are of an age where they are expected to enter unaccompanied by their parent. The concern seems greatest for mothers of trans boys. Mothers can feel less confident at instructing their sons about male bathroom culture as well as have greater fear of predatory behavior from strangers.
Some suggestions to be restroom-ready:
1. Role-play different scenarios from the practical, the ridiculous, and the serious. Get on a trans parent email list and ask for some “bathroom stories.” Likely, you will get so many varied responses that there will be no problem getting a child prepared for just about anything.
2. Trans children, teens, and adults are not the only ones who struggle with adapting to “bathroom culture.” There are a surprising number of books that present many bathroom do’s and don’ts and offer great tips for taking care of business.
3. Instruct your child on basic safety issues regarding any interaction with a stranger and what to do if they feel uneasy or scared.
4. Parents: Remember, bathrooms are not sacred territory! If your child is using a different restroom than you and it is taking longer than expected, do not hesitate to (1) give a shout into the restroom, (2) enlist the help of another person in that restroom, or (3) simply go right in to get your child. Nothing trumps the safety of your child.
Gender-separated activities are everywhere—not just schools. Parents can face a perplexing challenge when considering overnight camps, after-school programs, sports, and other group activities. The issue of whether to disclose a child’s gender status or keep it private may have been settled some time ago at school only to find that it crops up all over again for each new situation. Joining a sports team or attending a new camp or after-school program can be like starting from square one. Inclusive policies may or may not exist, and they may or may not be enforced. A camp administrator may propose that a transgender child attend the weeklong camp but stay in a separate cabin or with the adult chaperones in their cabin. To a child, this arrangement is the complete antithesis of why they would like to attend a camp. An instructor or coach may feel like the other parents “have a right to know” the child’s gender status and place different participation requirements on the transgender child.
Whatever the situation, know that an ounce of prevention is worth a pound of cure. Seek out any existing policy in advance. Provide examples of trans-inclusive school guidelines. Find out if any other trans children have ever attended/engaged in the activity and the pathway provided for their participation. There are situations across the country where various youth programs have had trans youth participation. Call them. Find out what they experienced and what they learned. If an entity has successful experience(s), see whether they have a policy that reflects that. Ask whether an administrator, coach, or other program head would be willing to discuss this with the camp or troop you are considering for your child. Unfortunately, there have been too many situations where a family is left with no alternative but to pursue legal assistance.
Nicholas M. Teich
Campers hiking at Camp Aranu’tiq.
Nicholas M. Teich is founder and president of Camp Aranu’tiq.
Summer camp meant a great deal to me growing up, even before I was conscious of my transgender identity. I attended a traditional overnight camp in Maine, where I was a camper, counselor, and eventually a member of the camp’s leadership. Later on, I began to volunteer at a separate nonprofit camp. In 2007, after several years volunteering and being involved in the nonprofit camp, I was abruptly told that I could not return because my impending gender transition would apparently be detrimental to the well-being of the kids. That hurt. A lot.
Once I dusted myself off and gained some perspective, I began to think: How do kids who identify as trans or gender-variant go to overnight camp? I believed they must face rejection in droves, and unfortunately I was correct. I set out to start a safe place for these youth. When I founded Camp Aranu’tiq in early 2009, I could never have dreamed of the impact the campers would have on me.
The locations of our camps remain undisclosed to the best of our ability. It’s unfortunate that this has to be the case, but we live in a world where people fear difference. Our first summer week began in 2010, with 41 campers at a quaint Connecticut camp overlooking a stunning waterway. We grew in 2011 and again in 2012, expanding to another week at a location in California. In 2014, we will have 5 camps for ages 6–18, including a family camp, and we will serve over 300 campers.
Camp Aranu’tiq (a word that describes someone who transcends gender boundaries and is revered for it, in the Yu’pik language) was established with the express purpose of giving transgender and gender-variant kids a place where they could connect with one another and still have a typical overnight camp experience. In other words, Aranu’tiq would not be a place where we sat around in groups and talked about gender or what it was like to be seen as “different” in school or in our home communities. These children have to defend and talk about their gender enough outside of camp. Camp would just be camp.
Though we do not have formal talks about gender, the campers take it upon themselves to talk a lot about their shared experiences. This happens organically around the dinner table, while waiting in line for the restroom, or even while playing ball or crafting a skit in drama class. One of the funniest moments from our first summer was witnessing a group of teenage trans boys completing a low ropes course element where they had to come through a tunnel of ropes and out the other side. When they emerged, their friends shouted, “It’s a boy!” and they deemed it their “rebirth.”
I’ve learned a lot from our campers. They often don’t feel beautiful, handsome, or confident in the outside world—but at camp, they do feel this way. It’s the simplicity of being with others like them and being encouraged by adult role models, some of whom share their transgender or gender-variant identity, and some of whom do not. They occasionally complain, talk back, and cause unnecessary drama like any other kids. They prefer fried chicken and ice cream to baked salmon and fruit. They sometimes insist on wearing dresses and high heels to go canoeing. They might not get to wear these outfits at all outside of camp or the privacy of their own bedrooms, so they are going to make the most of it, common sense be damned.
In 2012, we had a preapproved visitor to camp who told me a few times that she was struck by how much like any other camp we were. That is all I ever wanted to show an outsider. Many people believe that transgender kids will look and act differently than non-trans kids in ways that I believe they cannot even picture in their minds. I am unsure if they are expecting a circus or a Jerry Springer episode or what, but those of us who know what a day in the life of Camp Aranu’tiq looks like know that they would be shocked and even bored by the mundaneness of kids running, playing, doing crafts, swimming, and laughing. That was the plan all along.
People always ask what happens after the camp week is over. For the past two years we have done a six-month postcamp survey and found that the vast majority—in fact almost all our campers—are in touch with others on a regular basis. Many of them have told me that they met their best friends at Camp Aranu’tiq. We encourage these bonds. After a tough day at school, it’s wonderful for them to be able to call or connect with a camp friend who understands what they are going through. I consider myself incredibly lucky to be able to watch our campers grow and change from year to year, and I can’t wait to see what amazing adults they grow to be.
Even teachers who are completely on board in their support of a gender nonconforming child in their classroom may find themselves at a loss for words when another child says, “Why does Sam wear dresses to school? That’s stupid!” How should they respond? What are the actual words?
If this comment were addressing a topic with which the teacher had familiarity, the response might feel like a no-brainer. But because many teachers often do not feel knowledgeable about issues related to gender, they are often caught off guard and end up saying nothing. Or they may not feel able to convert a child’s off-the-cuff remark into a “teachable moment” for simple logistical reasons. For example, the comment could have been said on the way to the lunchroom. The teacher again does not respond, feeling as if the comment needs to be handled in a gentle, thoughtful manner that might inspire a deeper conversation for that particular student or for the whole classroom.
The reality is that the gender component of the conversation does not necessarily need to be addressed in depth if that is not realistic. However, no response at all can imply implicit approval. The critical part of the comment to address is the denigrating “That’s stupid!” A reasonable and appropriate response could be something like “Sam likes to wear dresses and, at our school, we believe every student has the right to be exactly who they are. What we DON’T do at this school is make fun of anyone for any reason. It is not OK to call someone stupid, and I am asking you not to do that anymore.” The gendered component of the initial comment was addressed simply—without ignoring or overexplaining it—but the more harmful element (“Sam is stupid”) was handled swiftly. If there are any further denigrating comments, the teacher is easily positioned to follow up with any disciplinary action based solidly on school policy (no teasing or bullying).
A large percentage of children are teased and bullied because of atypical gender expression even in the earliest grades. Often teachers and other support staff feel helpless to intervene because femininity in a boy and masculinity in a girl are viewed as indicators of future gay or lesbian sexual orientation.
“Davey is a sissy!”
“Why does Keisha look like a boy?”
If a teacher’s first thought is that Davey will grow up to be gay or that Keisha may eventually be a lesbian, they have just inadvertently categorized this situation as one that is about sexuality—and therefore off limits for discussion with younger age students. Because of this, the unwelcome comment or question goes unaddressed. But this situation is about gender, not sexuality, and can be addressed with children of any age. Silence on the part of the teacher allows the teasing to go unchecked and worsen. No response can offer implicit approval for continued teasing and bullying.
Changing schools can be stressful but can also be an opportunity for a gender nonconforming or transgender child to have a fresh start. When efforts to address school problems at the administrative level have not been successful, some families consider a different school for a child. Other families consider a change of school at the point that a child begins to socially transition because it can provide an opportunity to “start fresh.” This new start can sometimes be just what a child needed. On the other hand, it is important to consider that information spreads easily between parents, administrators, and students at different schools, so a new school may not mean a group of people who are unaware of a child’s past.
Some families with means find that private schools are more welcoming than public schools. Others discover that homeschooling, online school, or other alternative educational options fit their children well. There are homeschooling groups where parents and children meet up to work on projects together, and many of these are supportive of gender nonconforming children. An argument that is sometimes presented against alternative schooling options is that the child misses out on important socialization opportunities. However, if a child is being teased, bullied, harassed, or assaulted at school, positive socialization opportunities are lost.
The decision to pursue medical intervention with gender nonconforming youth can be complicated and is unique to each family. The possibility of medical intervention is important to talk about early, and with a supportive pediatrician or family doctor. Building relationships with experienced health care providers can be extremely rewarding, and doing this early can prevent feelings that a family is rushing at the last minute to explore options.
In addition to mental health providers, many families of gender nonconforming children benefit from connecting early with a supportive pediatrician or family doctor. For some families, it is also important to see a pediatric endocrinologist, who specializes in hormones and children’s bodies.
General pediatricians working in communities often have little training in working with gender nonconforming children. Some are eager to learn. Many families have established relationships with their pediatricians and want to continue working with them, while others feel more comfortable finding new pediatricians who have more experience working with gender nonconforming children. Children come into contact with other types of medical providers such as nurses and dentists on a regular basis, and it is appropriate to request and expect these providers to use the proper name and pronoun for a child during all interactions. If a pediatrician or other health care provider is not respectful of a family’s wishes, it may be important to change providers.
Pediatric endocrinologists are pediatricians who specialize in hormonal disorders such as diabetes and growth problems. Many pediatric endocrinologists are not familiar with treatments for gender nonconforming children, although they use the same medications (puberty blockers) to treat growth disorders. Like many pediatricians, pediatric endocrinologists are often eager to learn about gender nonconforming children. There are a few who specialize in this area. Puberty blockers can be prescribed by a general pediatrician, family practitioner, or a pediatric endocrinologist. A number of providers find that, with adequate resources or consulting opportunities, the endocrine care of preadolescents falls well within their scope of practice.
Many of us feel comfortable with the providers our children are already seeing and would like to continue seeing them. If this is true, it can be important to schedule a special visit to talk about our child’s gender identity. If the child has been assessed by a therapist, state that. If you are supportive of your child’s identity and/or their gender exploration, state that as well. It is helpful for the doctor to have a snapshot of your family’s process so they can best determine where their responsibility begins and ends. Determine your objective for the visit. Are you just updating them on the current state of events? Wanting continued care for your child, including medical interventions? Start with the former, regardless of later needs. Doctors are just like anyone else and may have unpredictable emotional reactions. If you have a doctor who expresses support and willingness to learn, that is great. They may look to you to point them to resources, connect them to providers with whom they can consult, or to answer their direct questions related to concepts of gender diversity.
A Sampling of Medical Clinics for Transgender Children
• Center for Transyouth Health and Development, Children’s Hospital of Los Angeles
• Child & Adolescent Gender Center Clinic, UCSF Benioff Children’s Hospital
• Gender & Sexuality Psychosocial Programs, Children’s National Medical Center, DC
• Gender & Sexuality Service, New York University
• Gender Management Service (GeMS), Boston Children’s Hospital
• Gender, Sexuality and HIV Prevention Center, Lurie Children’s Hospital of Chicago
You may find that your child’s current doctor is unwilling or lacks the confidence to care for your child. Or perhaps you prefer to not put yourself in the educator role. Selecting a new doctor then becomes the next step. Calling or e-mailing a doctor’s office to assess their experience and willingness may not be enough. The front desk staff may insist the doctor does not provide this care when indeed they do. Or a scheduler may tell a new caller that the doctor’s practice is full when the provider actually makes exceptions for new transgender patients. If at all possible, arrange for a direct conversation with the doctor.
Your local LGBTQ center may be able to refer you to experienced providers. You can also join an email list for parents of transgender children and ask for referrals. Other parents are one of your greatest resources for so many things related to this journey. If you make enough information-gathering inquiries, there may be a name or two that is mentioned again and again.
Johanna Olson, MD, is the medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles. Her career is dedicated to clinical care and research promoting authentic living for all youth.
The Endocrine Guidelines, published in 2009, recommend that children who are identifying as transgender or gender nonconforming when puberty begins can be placed on “puberty blockers,” a group of prescribed medications that suppress or inhibit a child’s unwanted pubertal development. Ideally, this intervention should be used as early as Tanner Stage Two (the second stage of puberty) for several reasons:
1. The effects of blockers are fully reversible. This means that if the medication is stopped, puberty will progress as it would have. While the use of these medications for transgender children is relatively recent, blockers have been used for decades to halt early onset of puberty in young children (a condition known as central precocious puberty).
2. Blockers can buy time for kids and parents. Delaying puberty allows for an amount of added time so that a child can continue in their gender exploration, if needed. Perhaps even more important, it serves to alleviate fears that parents or other adults may experience. It simply allows the time needed for them to gain increased confidence and certainty.
3. Blockers can optimize the development of preferred physical characteristics. In trans girls, blockers initiated prior to the development of male secondary sexual characteristics will effectively prevent voice deepening, skeletal enlargement, and penile enlargement. In trans boys, these early medications can prevent characteristics such as breast development, hip widening, and starting menstruation.
Medications most commonly used for puberty delay are called gonadotropin-releasing hormone (GnRH) analogs. GnRH is a hormone released from the hypothalamus in the brain to trigger the pituitary gland in the brain to release leutinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH stimulate the ovaries or the testes to secrete estrogen or testosterone. The easiest way to understand the role of GnRH analogs is to imagine the medication as a way to “block” the release of LH and FSH and, subsequently, estrogen or testosterone.
The GnRH analog mimics the action of the body’s natural GnRH. It bombards the pituitary, effectively shutting down the feedback loop. This is why occasionally, when adolescents are first started on blockers, they experience an actual increase in pubertal symptoms during the first month or so. This is temporary and usually recedes with time.
Puberty blockers come in two main forms: intramuscular injections or a surgically placed implant positioned in the upper arm. The injections happen either monthly or every three months. The implant (usually placed at an outpatient office visit) tends to last between 12 and 18 months, sometimes longer. Both forms of blockers are very expensive, although increasing numbers of insurance companies are starting to cover them. Pediatricians, family doctors, internists, gynecologists, and endocrinologists are all well suited to prescribe and deliver hormone blockers.
Trans girls (assigned male at birth) begin puberty on average between 11 and 13 years of age. The first sign of puberty is generally testicular enlargement. Trans girls should be advised to look out for these initial changes. This is important because, as trans children begin puberty, they are likely to be very unwilling to allow their parents to see their naked body, especially if they feel distress about their body. At Tanner Stage Two, a trans girl will have some testicular enlargement and some growth of adult-type pubic hair. This is the time to begin hormone blockers. Ideally, hormone blockers are initiated prior to any further development such as voice deepening, skeletal enlargement, or penile enlargement, as these characteristics are not reversible with feminizing hormones. Transgender girls who take puberty blockers are not going to be peer-concordant in their sexual development simply because the average male puberty begins two years later than the average female puberty. If a 12-year-old transgender girl begins puberty, goes on blockers, and gets on cross sex hormones even as early as 14, she will still be behind her female peer group in breast development. This may be a factor in deciding when to initiate cross sex hormones.
Trans boys (assigned female at birth) usually begin puberty between the ages of 9 and 11 years. Invariably, it almost always begins with the development of breast buds and, occasionally the development of a few adult-like pubic hairs, signaling Tanner Stage Two. Transgender boys need to be taught about the early signs of puberty so that they can alert their parents or caretakers that it is time for medical intervention. Transgender boys have a better chance of being peer concordant with regard to typical male sexual development, but they will likely be on blocking medication longer than transgender girls.
The most common concern regarding hormone blockers is that of diminished bone density. While there have been many studies examining the bone density of children who are prescribed hormone blockers for central precocious puberty, there has been only one small study considering this question in transgender youth. This study, undertaken in the Netherlands, showed that bone density was diminished during puberty suppression on GnRH analogs, but that it recovered with the addition of appropriate cross sex hormones, ultimately reaching appropriate levels. Any medical decision must weigh the benefits of use versus the risks (both known and unknown).
Cross sex hormones are used in those youth who persist in their transgender identity into adolescence and subsequently desire a physical body that matches their internal gender identity. Cross sex hormones are also used by adults who are beginning their gender transition.
Transgender young men may be treated with testosterone in order to suppress female physiologic traits and to enhance masculinization of the body. The primary goals of testosterone therapy are menstrual cessation, or primary amenorrhea (never starting menstruation), deepening of the voice, development of male pattern body hair, increased muscle mass, and clitoral enlargement. These processes occur at different stages of testosterone therapy, not unlike a typical male puberty. The timeline varies from person to person, and it usually takes years to be complete.
Transgender young women may take estrogen alone or in combination with testosterone blockers. Those on puberty blockers may not need to take testosterone blockers. The purpose of estrogen and testosterone blockers is to aid in the development of female physical characteristics while avoiding the development of the laryngeal prominence (Adam’s apple), deepening of the voice, development of male pattern body hair, testicular and penile enlargement, and excessive height.
Suppression of one’s naturally occurring puberty and the progression of the affirmed puberty will result in the inability of young people to have their own biological children. Additionally, trans girls who begin blockers at Tanner Stage Two and then proceed to cross sex hormones will not develop mature enough sperm to bank for future use. Trans youth should be made aware of their options with regard to fertility and the potential that they may not be able to have their own biological children if they start cross sex hormones. These are difficult discussions, but ones that should be had.
Puberty blockers and cross sex hormones are not for every youth or family. Puberty blockers can be prohibitively expensive for some, and not the right choice for others, but they are an option to be aware of and discuss.
For some families, especially those living in larger metropolitan areas, knowledgeable health care providers may be close by. However, for many people, reaching someone with experience may involve a plane ride that is not necessarily affordable. For those with means who live in remote areas, one option is to travel to see a more experienced provider in a larger city a few times a year, and to work with a local pediatrician. For those who cannot afford to do this, there may be a local physician who is willing to learn what is necessary to help. In either case, families may spend a considerable amount of time and effort educating providers about working with gender nonconforming children.
Adult transgender people often find that they need to provide resources and support to their providers. There is little taught in nursing, medical, or physician assistant programs about transgender health. While it can be extremely frustrating to have to educate providers, it can also be rewarding to see that their new knowledge is helpful to other families struggling with similar issues.
It is important to be aware that there are providers who are not knowledgeable about gender nonconforming children but may present themselves as such because they do not want to appear ignorant. Some may have knowledge that is outdated or that is only relevant to adult transgender people. If this situation presents itself, seek out a second opinion or change providers. On the other hand, there are some care professionals who may not know much but will readily own this. They will seek out more experienced providers with whom they can consult; find up-to-date research to enhance their learning; and, if possible, refer a family or child to someone better suited to meet their needs. If no adequate referrals are available, this proactive provider could still be an excellent choice.
One therapist who was eager to learn had this to say:
“A parent came to my practice to talk about her newly trans-identified child. As a lesbian, I wasn’t completely unfamiliar with transgender issues—I even had a trans man as a client—but, I had no idea how to help this parent regarding their trans child nor did I know anyone who could help. The next time I saw my adult client, I asked him if I could have 15 minutes of his time at the end of his session to discuss how I might best support this parent. I offered to give him a free session as well. He readily agreed and was so delighted in how I handled it! He said he’d already paid a number of therapists to find help for working on family-of-origin issues (not gender issues) and found that every one of them incessantly questioned him about his now years-old gender transition. He was so relieved by my approach that it not only was helpful to me and my other client but also deepened the trust that he and I had. Everyone benefited!” (Conversation with Aidan Key)
Raising a transgender or gender nonconforming child can be both exciting and scary. Being open minded and supportive, as well as seeking out resources and community, are important to creating an optimal environment for exploration. Providing children with loving homes, acceptance, and emotional tools builds the resilience and self-esteem that all people need to have happy and fulfilling lives.
REFERENCES AND FURTHER READING
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* Quotes in this chapter, when not otherwise specified, come from an online survey of parents/guardians of gender nonconforming children that accompanies the general Trans Bodies, Trans Selves survey.