Transgender Children and Youth

LATE ONE SUMMER AFTERNOON WHEN I WAS NINE YEARS old, my best friends, Charley and Nick, and I were out traipsing through the woods near our homes. We’d been there for hours playing our favorite game—police detectives hot on the trail of a murderer. The woods weren’t much to speak of, but they were ours. We hiked there, played there, caught tadpoles and built tree forts there. It was mostly just a field with trees that stretched on along the railroad tracks, but it was overgrown enough to be our private place away from watchful parental eyes. Just off from the woods behind a row of houses was the open field where we played baseball when we weren’t playing murder detectives.

That day we were deep into our roles, searching for clues to find the killer, when Nick raced off a few hundred feet ahead. A few minutes later, Charley and I rounded the path and caught up with Nick. On the left in the weeds was a dirty white 5-gallon bucket—the kind you buy paint in. It was nearly full of water. In an instant I could see the surface was bubbling. The air was thick with the smell of warm pee. Nick was zipping up his pants.

My crotch exploded—hot and tingly—with my own need to urinate. The urgency overwhelmed me. I wanted to unzip my pants and relieve myself like Nick. But what was even more overwhelming that afternoon was the crushing realization that I could not.

Charley and I were inseparable at that age, with Nick often in tow. We went everywhere together. We walked to school together. We played in each other’s yards. We teased our little sisters together. We sold snow cones together at the neighborhood teenage boys’ baseball games. Left to my own devices, inside my own head, I was one of them. I dressed like them, talked like them, felt like them. But in that moment by the paint bucket it was painfully clear that I was not just like them. My body was not like theirs.

By the age of 12, with the approach of puberty, I was depressed and suicidal. It was 1970. No one talked about gender identity or transgender people. There were no visible transgender role models, no transgender talk shows, and definitely no media stories about transgender teenagers. In the fundamentalist environment that surrounded me, no one even discussed lesbian or gay people. I was 16 years old before I knew what the words meant.

As a result, I spent my adolescence nearly drinking and drugging myself to death, trying to numb out all the ways it felt like my body was betraying me. I hated the way my chest was changing. I hated the monthly menstrual reminders that my body didn’t match the way I felt inside. I was profoundly self-conscious about my body and about people seeing my body. I wore long-sleeved shirts and long pants all summer. I didn’t go swimming unless forced to. Being in a bathing suit where my breasts were visible was unbearably dysphoric.

At that age and in that historical context, I did not have words to describe what was going on inside me. And I was afraid to begin to try telling anyone. Almost everyone I knew was a fundamentalist Christian, and I sensed they would not be OK with what I felt. I kept quiet and kept taking phenobarbital and drinking to keep my dysphoria and depression at bay.

I knew I was attracted to girls, and so, in late adolescence, when I discovered lesbians, I figured that must be what I was. A bit later I discovered there was such a thing as butch lesbians. That helped things fit a bit more—at least I could wear the clothes that felt like me, preferably a suit and tie.

Despite these struggles, I survived adolescence, graduated college with a bachelor’s in social work, and moved into my adult life. In my early thirties, I obtained my graduate degrees in social work and divinity and got sober. I moved through my life visibly Queer, given my masculine gender expression. Being a butch dyke was in many ways an alternate gender identity for me during this time. It didn’t fit quite right, but it seemed to be the best and only accommodation available.

After receiving my graduate degrees, I went to work at the Lesbian, Gay, Bisexual, and Transgender Community Center (then the Lesbian and Gay Community Center) in New York City. It was here that I began to understand gender identity and meet transgender women (at that time, trans men were still largely invisible). I left the Center to work as the regional director for a network of Metropolitan Community Church congregations in Texas, Oklahoma, Arkansas, and Louisiana (a denomination founded in 1968 with primarily a ministry in the LGBT community). When I returned to the Center four years later, I was actively thinking about my own gender identity and becoming increasingly aware that being a lesbian did not match my internal understanding of myself.

It took me a number of years to find the courage to come out. By this point, I was a well-established and respected social worker with a part-time private clinical practice and a wide network of colleagues throughout and beyond New York City. When I imagined coming out as a transgender man and beginning to transition, it felt like this would be the equivalent of throwing the deck of cards that was my life up in the air, not knowing where any one of them would land. I grappled over and over with whether being a man in the world was “worth” upsetting the entire apple cart of my life and relationships. I also wasn’t sure I had the courage it would take to come out and begin visibly and very publicly changing how I was viewed in the world.

Nevertheless, one morning I woke up and knew without a doubt that I must make this change. Despite having spent my adult life to date managing to live as a butch dyke, I knew I could not finish out the rest of my life that way. No matter what the consequences might turn out to be, it was no longer tolerable being perceived in a way that did not match my internal sense of myself, and so I began my own gender transition.

Since then, my clinical practice has become increasingly focused within the transgender community, and for the past nine years I have worked almost entirely with gender-diverse and transgender children, adolescents, and young adults and their families. The work is incredibly rich and meaningful to me. I am aware at the end of each day of the ways I make a difference in their immediate and emerging lives. I watch the ways they are able to become who they are in the world much, much earlier than those in my age cohort did. I am amazed at the incredible ways most of their parents show up for them and support them, even when the parents struggle to understand everything or perhaps aren’t entirely sure it’s truly OK to be transgender.

My own life narrative has been radically different on this front. There still is not much room within fundamentalist faith communities for LGBT people. When I came out initially as a lesbian, there was tremendous pushback. There were phone calls and letters about how being a lesbian was a sin. I was told being gay was an abomination to God and urged to repent and begin dating guys. As a result of coming out as a lesbian, I lost my family and my faith community.

My passion for working with transgender and gender-nonconforming youth and their families has evolved out of my own life narrative. It is rooted within my own loss and motivated by my desire to ensure that other trans youth and their families stay connected. Despite increased visibility, many transgender people continue to encounter hostility and discrimination in the world around them.

In a recent national study of over 27,000 transgender adults, nearly half (48%) of all respondents reported being denied equal treatment, verbally harassed, and/or physically attacked in the previous year because of being transgender. Nearly one-third (29%) of respondents were living in poverty, more than twice the rate in the U.S. adult population (14%) (James et al., 2016).

Unemployment rates for transgender people were three times higher than those of the general population, with trans people of color unemployed two – three times more often (James et al., 2016). Sixteen percent (16%) of respondents who had ever been employed reported losing at least one job because of their gender identity or expression. Twenty-seven percent of those who held or applied for a job the prior year reported being fired, denied a promotion, or not hired for a job they applied for because of their gender identity or expression; fifteen percent (15%) of respondents employed in the previous year were verbally harassed, physically attacked, and/or sexually assaulted at work because of their gender identity or expression (James et al., 2016).

HIV infection rates among transgender people were nearly five times the national average, with rates higher among transgender people of color. One-third (33%) of respondents reported having at least one negative experience with a healthcare provider in the prior year related to being transgender (James et al., 2016).

While there is increased media coverage about transgender children and teens, our world is still not an easy place to grow up transgender. Most parents, daycare workers, and kindergarten and elementary school teachers do not know much about gender difference among children. Many people still believe that gender-nonconforming or diverse behavior among children is “wrong” and should not be tolerated, let alone accepted.

There are still medical doctors and mental health professionals who counsel parents to correct or “punish” young boys who like to play with girls’ toys, like the colors pink and purple, or want to wear a princess nightgown to bed. They tell parents to take away the girls’ toys, to not allow their gender-different boys to play with girls or play girls’ games or activities, and instead to insist upon only stereotypical masculine clothes, toys, activities, and playmates.

Many people, even mental health professionals, believe that a child cannot know they are transgender. They insist it is impossible for a 4-year-old, 7-year-old, 11-year-old, or even a 14-year-old to know yet that they are transgender. So the first hurdle for any transgender child or adolescent is simply getting people to believe that they are who they say they are, that they are in fact who they know themselves to be in terms of their gender identity, that they are capable of knowing whether they are a boy or a girl (or both or neither).

If the young person manages to convince their parents that they are who they say they are despite the sex they were assigned at birth, the next hurdle often involves whether or not that child or adolescent should be allowed to begin living in their identify gender. Gender transition is still challenging for adults. It can be even more difficult to navigate for children and adolescents.

All of us as human beings, whether children or adults, want to be seen in the world. And all of us want to be seen for who we really are, for who we know ourselves to be. We also want our identity to be acknowledged and validated by those around us—particularly by the people who are important to us, the people we love and who love us, our family.

All of us long to be in relationships where we are free to be who we are, where we are loved for who we are—and not in spite of who we are. All of us long to be in relationships and communities where we can bring our whole selves. None of us want to have to hide parts of who we are. None of us want to compartmentalize parts of ourselves, to be forced to pick and choose which parts of us are “acceptable” or “safe” within a particular relationship or environment. Transgender children and adolescents want these things too.

During December 2014, the story of Leelah Alcorn, a 17-year-old transgender girl, went viral. Leelah was raised in a conservative religious home. When she came out as transgender at age 14, her parents did not accept her identity as a young woman. When she requested to begin medically transitioning at age 16, her parents sent her to a religious therapist whose goal was to convince Leelah to accept her birth-assigned sex as male. When Leelah began coming out to friends, her parents pulled her out of school and took away her Internet privileges.

Leelah’s profound gender dysphoria, coupled with the refusal of those she loved to acknowledge her identity as a young woman and her increasing isolation, led, as it often does in transgender adolescents, to depression, despair, and hopelessness.

On December 28, 2014, Leelah posted a note to go live on Tumblr and then ended her life by walking out into traffic on an interstate near her home in Ohio. Excerpts from the note she left spoke directly to those left behind:

If you are reading this, it means that I have committed suicide.

Please don’t be sad, it’s for the better. The life I would’ve lived isn’t worth living … To put it simply, I feel like a girl trapped in a boy’s body, and I’ve felt that way ever since I was 4. I never knew there was a word for that feeling … so I never told anyone…

When I was 14, I learned what transgender meant and cried of happiness. After 10 years of confusion I finally understood who I was. [My family told] me that it was a phase … that God doesn’t make mistakes, that I am wrong. If you are reading this, parents, please don’t tell this to your kids… That won’t do anything but make them hate them self. That’s exactly what it did to me…

The only way I will rest in peace is if one day transgender people aren’t treated the way I was, they’re treated like humans, with valid feelings and human rights. Gender needs to be taught about in schools, the earlier the better. My death needs to mean something. My death needs to be counted in the number of transgender people who commit suicide this year. I want someone to look at that number and say “that’s fucked up” and fix it. Fix society. Please.

Goodbye,

(Leelah) Josh Alcorn (Lowder, 2014)

For many transgender people, one aspect of gender dysphoria is the profound feeling or awareness that your body does not match your own sense of who you are. This can be particularly acute for adolescents as they enter puberty and begin developing secondary sex characteristics that do not match their internal gender identity as a young man or young woman. For nonbinary or transgender adolescents who have sensed from early childhood that their gender identity, or the ways their gender identity was perceived in the world, did not fit them, it can seem like their body is betraying them when puberty begins.

Some preteen transgender children harbor the belief that when they grow up, they will be the woman or man they know themselves to be—even if people around them can’t see that now. The emergence of secondary sex characteristics shatters that belief. Instead of becoming the young woman or young man they know they are, it is suddenly apparent that their bodies are developing into an adult self that matches the sex they were assigned at birth rather than their internal sense of identity. For these transgender adolescents, the risk of depression, hopelessness, and suicide is acute, especially when coupled with lack of family acceptance (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010).

National studies of transgender adults indicate that 40% have attempted suicide at some point in their lives, compared to only 4.6% in the general population (James et al., 2016). Rates are even higher among those who had lost a job due to bias (55%), have been harassed or bullied in school (51%), have experienced homelessness (59%), or have been the victim of physical assault (61%) or sexual assault (64%) (Grant et al., 2011; James et al., 2016).

These statistics indicate the profound risks of living with gender dysphoria and not being recognized and accepted for who we are in the world. Leelah Alcorn is only one of many transgender adolescents who have taken their own lives because they despaired of ever being able to be who they were in the world or ever being accepted for who they were. Two years ago, on the heels of several local and national trans people committing suicide, I spent an entire summer listening to my transgender clients talk about nothing else. Their grief was palpable. It also triggered all the moments they, too, had despaired about navigating their trans identities in a still often unaccepting world.

These realities compelled me to write this book. The more social workers, psychologists, school counselors, family therapists, and other mental health providers understand gender identity and expression, and the more we learn about the experiences and needs of transgender and gender-diverse youth and their families, the greater the possibility that we can not only prevent other transgender children and adolescents from taking their own lives but also enable them to live rich and fulfilling lives as adults. The more families, teachers, and youth workers know how to communicate acceptance and support for the trans and gender-diverse youth in their lives, the greater the possibility these young people will grow up to become healthy, happy, productive happy young adults. Sometimes even one person can make a difference.

I have woven vignettes throughout each chapter because I believe in the power of stories to illuminate the nuances of our varied lives. Stories touch our minds and emotions enabling us to connect across our differences. I have chosen to respect the stories young people and families have shared with me by creating composite characters and families that reflect the varied, yet common, experiences of transgender children and adolescents and the people who love and cherish them.

None of the vignettes reflect a single young person or one specific family. Instead, I have interlaced themes, questions, joys, and challenges in ways I hope will lead you to a greater understanding and appreciation for their incredible creativity, courage, resilience, and determination to hold love as the most important thing in our lives.

CHAPTER 1 defines core concepts and ideas such as sex, gender expression, gender identity, and sexual orientation and covers basic vocabulary used within trans and gender-nonconforming communities by both young people and adults.

CHAPTER 2 explores gender variance and gender diversity among children and adolescents. It reviews historical responses to gender-nonconforming children as well as historical and current theoretical and clinical approaches for working with these children and their families. It offers an overview of the evolution of DSM criteria for gender identity disorder (DSM-III and DSM-IV) alongside commentary on the advantages and limitations of the current DSM-5 shift to a diagnosis of gender dysphoria.

CHAPTER 3 focuses on how to understand gender diversity and dysphoria among children and adolescents in today’s culture. It outlines what is needed for a diagnosis of gender dysphoria and discusses the benefits and costs of the diagnosis. It also explores the process of supporting young children whose gender expression does not conform to what is stereotypically viewed as normal for either young boys or girls. These are children who have not declared a transgender identity in the sense of stating that their birth-assigned sex conflicts with their gender identity. Their understanding of themselves may or may not evolve over time to the point of wanting to gender transition.

CHAPTER 4 explores the scope and challenges of disclosing a transgender identity for youth and their families and outlines the basic steps involved with social (no medical interventions) transition.

CHAPTER 5 describes the various aspects of medical transition, including hormone therapy and different surgical interventions. Detailed information about the use, potential benefits, and possible concerns about the use of hormone blockers is presented. Feminizing and masculinizing hormone therapy is reviewed, including basic protocols, possible risks, and benefits. Information about various surgical interventions is presented in the latter section of the chapter.

CHAPTER 6 discusses the emergence of transgender identity in adolescence, including the role of the onset of puberty-specific dynamics unique to nonbinary youth. Risk factors for trans adolescents are highlighted as well as aspects of their resilience. The chapter discusses the range of challenges trans youth of color may encounter and presents guidelines for effective work with these young people.

CHAPTER 7 describes dynamics affecting parents and caregivers of gender-diverse and transgender children and adolescents with the goal of preparing mental health professionals to support these young people and their families, as well as normalize family tasks and challenges. Almost all families, and parents in particular, experience a wide range of emotional responses as they navigate their child’s journey with gender diversity and/or gender transition. The chapter concludes by outlining the knowledge and resources families of transgender and gender-nonconforming children need to effectively parent these young people as well as interact with a variety of medical and mental health providers.

CHAPTER 8 explores more complex work with families, including situations when families disagree about whether a child is transgender or what steps should be taken next in a child’s transition. It addresses work with parents from more conservative faith traditions and strategies for moving parents toward greater acceptance.

CHAPTER 9 focuses on issues that often arise within schools, as well as needs and potential challenges that may emerge within other types of youth programs and settings. The role of parents and professionals as advocates in ensuring that these environments are inclusive and affirming is emphasized. The final section presents ways to create a welcoming environment for transgender children and teens.

CHAPTER 10 explores more advanced clinical interventions with trans adolescents, focusing on the kinds of challenges and themes that may emerge after the initial wave of coming out and transitioning to life in their affirmed gender. There is very little existing literature that addresses advanced clinical work with trans youth.

CHAPTER 11 discusses questions that can arise as transgender young people are launched and move into the world of work or attend college.

PART THREE: SUPPORTING TRANS YOUTH addresses the specific role and responsibilities of mental health providers and concludes with a review of life-affirming practices that can make a difference in the lives of transgender and gender-diverse children and adolescents.

CHAPTER 12 reviews the role and tasks of mental health professionals as outlined in the World Professional Association for Transgender Health (WPATH) Standards of Care, including the challenges that can emerge as a result of the “gatekeeper role.” The chapter explores our internalized attitudes and beliefs and how these may interfere with effective clinical practice with trans youth. Possible provider “missteps” that can pose barriers in the therapeutic relationship are discussed.

CHAPTER 13 outlines the top ten life-affirming practices for adults in the lives of trans kids. It summarizes ways that all of us—teachers, counselors, therapists, parents, and others—can create space for trans and gender-diverse youth to safely explore, understand, and inhabit their individual experiences of gender. It offers guidelines to protect and enhance their self-esteem, strategies to help them survive and thrive in the face of internal and external stressors, and ways to partner with them to cultivate hope for the future.

Several appendices are located at the end of the book. APPENDIX A provides an overview of legal concerns that can emerge in work with transgender and gender-nonconforming youth and their families. It includes information about legal name changes and changing gender markers on identification documents. It reviews the current state of legal rights and relevant precedent supporting transgender children and adolescents moving through the world in their affirmed gender. Particular attention is paid to respect and access to the same facilities and opportunities afforded their cisgender (non-transgender) peers. APPENDIX B offers an extensive compilation of resources for clinicians, trans and gender-diverse youth and their families, and other service providers. APPENDIX C contains sample mental health letters needed before youth can proceed with hormone therapy or surgeries.

Major changes occurred rapidly during 2016. North Carolina’s HB2 law has targeted bathrooms and pushed transgender issues to the forefront in the media and at the water cooler; an Oregon court ruled that non-binary is a legal gender; the U.S. Departments of Education and Justice issued a directive to schools prohibiting discrimination against transgender students, including granting them the right to use the bathrooms and locker rooms that match their affirmed gender; and the U.S. Department of Health and Human Services’ final rule on Section 1557 of the Patient Protection and Affordable Care Act explicitly prohibited discrimination based on gender identity and sex stereotyping in any hospital or health program that receives federal funds as well as prohibiting discrimination within most health coverage. Health insurance companies can no longer categorically deny medical procedures simply because the member is transgender or the procedure is related to their gender transition. Yet at the same time, a Georgia judge refused to issue a name change for a transgender man because the judge did not believe it was right for “her” to assume a male name (Bowling, 2016).

In the midst of these exciting and contradictory changes, my goal in working with trans and gender-diverse youth is not focused primarily on gender transition. My most important goal centers around enabling families to create space, love, and support for these children and adolescents to explore and live out their gender identity and expressions freely, without reproach or shame, and for each one of these young people to not be confined by a set of rigid expectations about what is “acceptable” masculine or feminine gender expression or identity but instead to live their whole true selves in each moment in ways that feel authentic to them.

For some young people, this will mean space to express their gender in a wide array of possibilities. It may mean permission for boys to play with dolls or trucks, to wear lavender or navy blue, to decide to be a construction worker or a dancer when they grow up. It may mean girls being free to choose math and science or art and music, playing football or playing princess, wearing combat boots or wearing heels.

Some youth will go beyond gender diversity to express a clear and consistent transgender identity. Their desire will be to transition so that they can live and be acknowledged in the gender they know to be true for them. Other youth will choose neither of these; they are already hurtling beyond the gender binary and daring all of us to catch up with them.

My intention throughout the book is to provide the knowledge and skills mental health professionals, schools, and families need to effectively support these children and adolescents. To do the work of enabling parents to “sit with” gender diversity and not rush toward transition. To teach children and teens to be unafraid to embrace their gender in all its diversity and gain the tools needed to thrive in a world that can sometimes be ridiculing or hostile, and other times amazingly affirming and celebratory. To partner with and empower youth and their families for whom gender transition is the next “right” step. To remember to always hold love as the most important thing.